Columbia  Wini\itxsiitp  y^\^-\^ 
College  of  ^fjp^iciansi  anb  burgeons 


^tltvtntt  Hihvavp 


DISEASES  OF  WOMEN 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofwomenOOcros 


Fig.    1.      Antero-posterioi"    Section    of   Pelvis    (semi-diagrammatic). 


In  order  to  show  the  structures  and  relations  exactly  as  they  are  in  what  may  be  considered  a  typical 
woman  in  the  erect  posture,  a  detailed  study  was  made  of  many  drawings  from  frozen  sections  for  the 
internal  relations,  and  of  several  well-formed  women  in  the  normal  standing  posture  for  the  contour  and 
external  relations.  This  gave  a  result  differing  considerably  from  the  usual  representation  of  a  patient 
standing,  made  by  taking  a  drawing  of  a  section  of  a  flattened  cadaver  and  turning  it  upright,  The  lumbar 
curve  is  more  marked,  the  lower  abdominal  wall  and  the  buttocks  are  more  prominent  and  there  is  a 
change  of  the  relations  of  the  internal  organs  to  the   external  landmarks. 

For  the  internal  relations  the  admirable  frozen  sections  of  Sellheim  were  principally  followed,  and 
the  exactness  with  which  the  pelvis  and  contents  of  the  actual  sections  fitted  into  the  contours  of  the  living 
models  was  most  pleasing  and  instructive.  (Redrawn  and  colored  from  original  drawing  by  Dr.  R.  Waiter 
Mills.) 


DISEASES   OF   WOMEN 


T 


BY 


HARRY  STURGEON  CROSSEN,  M.D.,  F.A.C.S. 

ASSOCIATE    IN    GYNECOLOGY,    WASHINGTON    UNIVERSITY    MEDICAL    SCHOOL,    AND    ASSOCIATE    GYNE 
COLOGIST  TO  THE  BARNES   HOSPITAL;    GYNECOLOGIST   TO   ST.   LUKE'S  HOSPITAL,    MISSOURI 
BAPTIST    SANITARIUM   AND   ST.    LOUIS    MULLANPHY    HOSPITAL;    FELLOW    OF    THE 
AMERICAN    GYNECOLOGICAL    SOCIETY    AND    OF    THE   AMERICAN    ASSOCIA- 
TION  OF   OBSTETRICIANS  AND   GYNECOLOGISTS. 


FOURTH  EDITION,  REVISED  AND  ENLARGED 


WITH  EIGHT  HUNDRED  ENGRAVINGS 


ST.  LOUIS 

C.  Y.  MOSBY  COMPANY 

1917 


Copyright,    1907,   1910,   1913,   1917,   By   C.   V.   Mosby   Company 


Press  of 

C.   V.  Mosby  Company 

St.  Louis 


TO   THE    MEMORY    OF 

DR.  HENRY  HODGEN  MUDD 

THIS    WORK   IS   RESPECTFULLY 

DEDICATED 

AS   A   SLIGHT   TOKEN    OF   APPRECIATION 

OF 

HIS    SPLENDID   PROFESSIONAL   ATTAINMENTS, 

HIS   UNSELFISH   DEVOTION   TO   THE   CAUSE    OF   MEDICAL   EDUCATION 

AND   HIS   INSPIRING   PERSONAL   FRIENDSHIP 


PREFACE  TO  FOURTH  EDITION 

The  two  principal  additions  in  this  revision  are,  first,  numerous  draw- 
ings and  photomicrographs  illustrating  gynecologic  pathology;  and,  second, 
a  chapter  on  the  ductless  glands  in  their  relation  to  gynecology.  The  draw- 
ings and  photomicrographs  were  made  from  material  in  the  Gynecologic 
Laboratory  of  the  Washington  University  Medical  School,  and  in  their  prep- 
aration invaluable  assistance  was  rendered  by  Dr.  Otto  Schwarz,  in  charge 
of  the  Laboratory.  The  helpful  chapter  on  the  ductless  gland  system  w^as 
written  at  my  request  by  Dr.  Hugo  Ehrenfest,  to  whom  I  am  indebted  also  for 
his  great  kindness  in  seeing  the  book  through  the  press,  my  doing  so  being 
prevented  by  an  early  call  to  war  duty.  The  drawings  are  by  Mr.  Ivan  F. 
Summers  and  present  his  usual  satisfying  excellence. 

H.  S.  Crossen. 


PREFACE  TO  THIRD  EDITION 

The  scope  of  this  work  is  fully  set  forth  in  the  previous  editions.  The 
method  of  presentation  has  proved  so  satisfactory  that  no  change  is  indicated. 
Serologic  diagnosis  and  treatment,  as  applicable  in  gynecologic  work,  has 
received  consideration.  The  treatment  of  inoperable  cases  of  severe  uterine 
prolapse  and  eystocele,  has  been  given  special  attention  and  a  number  of  new 
drawings  have  been  made  to  elucidate  the  action  of  the  most  effective  pes- 
saries for  this  condition.  New  facts  have  been  added  under  a  number  of  other 
topics.  The  new  illustrations  are  by  Mr.  Ivan  F.  Summers,  whose  patience  and 
skill  I  much  appreciate. 

H.  S.  Crossen. 


PREFACE  TO  SECOND  EDITION 

The  character  of  this  work  is  indicated  in  the  extract  from  the  preface  to 
the  first  edition.  My  endeavor  has  been  to  present  clearly  and  in  detail  the 
foundation  facts  and  principles  of  Gynecology — the  anatomic,  pathologic, 
diagnostic  and  therapeutic  information  underlying  successful  gynecologic 
work. 

Two  hundred  pages  of  text  and  fifty  original  illustrations  have  been  added. 
The  index,  upon  which  the  practical  usefulness  of  a  medical  book  so  largely 
depends,  has  been  greatly  amplified,  so  as  to  include  references  and  cross- 
references  to  every  diagnostic  and  therapeutic  item.  In  the  new  text  special 
attention  has  been  given  to  the  presentation  of  pelvic  inflammation  and  of 
tubal  pregnancy — two  live  and  important  subjects,  upon  each  of  which  an 
enormous  and  chaotic  mass  of  information  has  accumulated.  To  properly 
emphasize  the  established  landmarks  and  point  out  important  features  of 
advance  work — such  was  the  task.  Disturbances  of  function  merit,  and 
have  received,  careful  and  detailed  consideration,  both  from  the  diagnostic 
and  therapeutic  standpoint.  Medico-legal  complications  are  claiming  more 
and  more  attention  each  year,  and  those  connected  with  gynecology  are 
considered  in  a  detailed  and  practical  way. 

My  thanks  are  due  to  Mr.  Thos.  Jones,  the  artist,  for  the  careful  Avork 
shown  in  the  new  drawings. 

I  would  appear  remiss  in  gratitude  did  I  not  express  my.  appreciation  of 
the  gratifying  reception  accorded  the  first  edition  by  teachers  and  prac- 
titioners. 

H.  S.  Crossen. 


EXTRACT  FROM  PREFACE  TO  FIRST  EDITION 


This  work  is  devoted  exclusively  to  the  diagnosis  and  treatment  of  Dis- 
eases of  Women  as  those  diseases  are  met  with  in  the  office  and  at  the  bed- 
side by  the  general  practitioner.  No  space  is  given  to  other  considerations, 
except  as  necessary  to  bring  the  work  to  its  highest  usefulness  as  a  prac- 
tical guide  in  the  lines  indicated.  While  no  space  is  taken  up  with  detailed 
technical  descriptions  of  major  operations,  much  care  is  taken  to  set  forth 
clearly  the  differential  diagnosis  of  the  various  conditions  requiring  such 
operative  treatment,  the  kind  of  operation  called  for  by  the  particular  con- 
ditions present,  what  the  operation  is  intended  to  accomplish,  the  prepara- 
tion of  the  patient  for  operation  and  the  after-care  necessary  to  complete 
the  restoration  to  health. 

In  my  experience  as  a  consultant  and  as  a  teacher  I  find  that  the  two 
principal  stumbling-blocks  encountered  in  the  way  of  accurate  gynecologic 
work  are,  first,  the  difficulty  of  determining  exactly  the  conditions  present  in 
the  pelvis,  and,  second,  the  lack  of  a  clear  understanding  of  the  indications 
governing  the  selection  of  the  particular  treatment  best  adapted  to  each  of 
the  various  classes  of  cases  under  each  disease.  Special  consideration  is 
given  to  these  important  phases  of  the  subject. 

My  endeavor  throughout  has  been  to  present  the  important  points 
CLEARLY  and  SYSTEMATICALLY — SO  clcarly  and  so  systematically  that  they  will 
be  readily  understood  and  well  retained  in  mind  for  use  at  the  bedside.  To 
this  end  much  thought  has  been  given  to  the  arrangement  of  the  text,  so 
as  to  shoAv  not  only  the  facts  of  a  subject,  but  also  the  mutual  relation  of  the 
facts  and  their  bearing  and  relative  importance  in  the  diagnosis  and  treat- 
ment. The  necessary  facts  are  presented  clearly  and  fully,  and  unincum- 
bered by  the  vast  and  confusing  mass  of  gynecological  knowledge  with  which 
the  specialist  must  deal. 

To  this  end,  likewise,  the  illustrations  have  been  most  carefully  selected, 
with  the  one  idea  of  making  clear  the  points  under  consideration.  From  the 
extensive  field  of  gynecological  literature  I  have  endeavored  to  bring  the 
BEST  illustration  available .  to  elucidate  each  point.  Those  from  reference 
works  necessarily  cover  a  wide  range,  and  I  wish  here  to  express  my  hearty 
thanks  to  the  authors  and  publishers  of  the  works  so  used. 

I  have  added  over  two  hundred  and  twenty  illustrations  of  my  own.  In 
these  I  have  endeavored  particularly  to  show  the  actual  care  and  handling  of 
the  patients,  thus  bringing  to  those  who  have  not  had  the  opportunity  of 
gynecologic  hospital  training  many  facts   which   can  be   satisfactorily   pre- 

9 


10  .  PREFACE 

seiitecl  in  no  other  M'ay.  For  tliis  purpose  I  have  had  taken  over  five  hun- 
dred photographs.  Only  a  part  of  them,  however,  could  be  used  in  this  work 
on  account  of  limited  space.  ]Most  of  these  photographs  were  taken  by  my 
clinical  assistant,  Dr.  E.  E.  AVobus,  to  whose  skill  and  patience  I  bear  appre- 
ciative tribute. 

My  thanks  are  due  to  my  colleague,  Dr.  Henry  Schwarz,  Professor  of 
Obstetrics  in  AVashington  University,  for  helpful  suggestions. 

I  wish  to  thank  Dr.  F.  J.  Taussig  and  Dr.  H.  A.  Hanser,  my  Senior  Clin- 
ical Assistants,  for  valuable  help  in  various  ways. 

To  Dr.  R.  AY.  Mills,  the  artist,  I  wish  to  express  my  appreciation.  His 
painstaking  care  and  fidelity  in  representation  are  apparent  in  all  the  draw- 
ings made  by  him. 

For  engravings  of  instruments  I  am  indebted  to  Mr.  C.  AA\  Alban,  instru- 
ment dealer,  of  this  city. 

The  publishers  have  aided  me  throughout  by  their  courtesy  and  cordial 
cooperation,  for  which  I  wish  to  express  my  sincere  thanks. 

H.  S.  Crossen. 


PUBLISHER'S  NOTE 

Having  barely  started  on  a  thorough  revision  of  this  volume  for  its 
fourth  edition,  Dr.  Harry  Sturgeon  Crossen  Avas  called  to  active  war  duty  as 
a  member  of  the  Medical  Officers  Eeserve  Corps. 

Many  new  illustrations,  most  carefully  selected  and  prepared  by  him 
in  the  course  of  the  last  few  years,  and  notes  in  regard  to  the  many 
changes  contemplated  were  turned  over  to  Dr.  Hugo  Ehrenfest,  Professor  of 
Obstetrics  and  Gynecology,  St.  Louis  University,  who  willingly  had  accepted 
Dr.  Crossen 's  request  to  finish  the  preparation  of  the  manuscript  for  the  new 
edition. 

We  gratefully  acknowledge  Dr.  Ehrenfest 's  valuable  and,  indeed,  en- 
thusiastic aid  in  accomplishing  this  difficult  task  within  a  very  limited  time. 

A  comparison  with  the  last  edition  will  readily  show  the  extent  and 
thoroughness  of  his  work.  The  latest  advances  in  the  science  and  iDractice 
of  gynecology  find  their  proper  consideration  in  every  part  of  this  new  vol- 
ume. In  a  special  chapter  the  important  and  interesting  problem  of  the  rela- 
tion of  the  endocrin  gland  system  to  gynecology  is  discussed  by  him,  more 
comprehensively  and  systematically  than  ever  before  attempted  in  any  text- 
book of  gynecology.  If  the  very  carefid  reader  here  and  there  should  dis- 
cover minor  incongruities  of  thought  or  advice,  we  trust  he  will  excuse  them 
by  remembering  the  difficulties  under  which  this  thorough  revision  actually 
has  been  accomplished. 


CONTENTS 


CHAPTER  I 

Gynecologic  Examination  Methods 

History,  33 ;  Physical  Examination,  44 ;  Abdominal  Examination,  46 ;  Examination  of 
External  Genitals  and  Adjacent  Structures,  62;  Vaginal  Examination  (Digital),  69;  Vagino- 
abdominal Examination  (Bimanual),  83;  Recto-abdominal  Palpation,  107;  Bimanual  Examina- 
tion of  a  Virgin,  108;  Recto-vagino-abdominal  Palpation,  109;  Palpation  of  Coccj'x,  110; 
Instrumental  Examination,  111;  Pelvic  Examination  Under  Anesthesia,  127;  Preparations 
for   Gynecologic   Examination,   138;   Non-Gynecologic  Examination   Methods,   152. 

CHAPTER  II 

Gynecologic  diagnosis 

Prominence  of  the  Abdomen,  164;  Movement  of  Abdominal  Wall,  181;  Discoloration  of 
Abdominal  Surface,  181;  Tension  of  Abdomen,  182;  Tenderness  in  Abdomen,  183;  Mass  Felt 
on  Abdominal  Palpation,  191;  Area  of  Dullness  in  Abdomen,  195;  Points  in  the  Examination 
of  External  Genitals,  209;  Points  in  the  Vaginal  Examination,  261;  Points  in  the  Vagino- 
abdominal Examination,  275 ;  Mass  or  Induration,  291 ;  Points  in  the  Differential  Diagnosis 
of  Various  Masses  in  the  Pelvis,  327 ;  Points  in  the  Speculum  Examination,  329 ;  Pain  in 
Pelvis  or  Lower  Abdomen,  337;  Backache,  343;  Reflected  Pains,  343;  Disturbances  of 
Function,  344, 

CHAPTER  III 

Gynecologic  Treatment 

Rest,  347 ;  Applications  to  the  Lower  Abdomen  and  Exterior  of  Pelvis,  348 ;  Applications 
to  External  Genitals,  Vagina,  and  Cervix,  353 ;  Intrauterine  Treatment,  391 ;  Applications 
within  Rectum,  404 ;  Applications  to  the  Lower  Abdomen  and  Interior  of  Pelvis,  405 ;  Appli- 
cations to  Body  Generally,  412;  Postural  Methods  and  Exercise,  414;  Internal  Treatment,  417; 
Operations,  420. 

CHAPTER  IV 

Diseases  op  the  External  Genitals  and  Vagina 

Points  in  Anatomy,  421 ;  Classification  of  Diseases,  431 ;  Gonorrhea,  431 ;  Simple  Vulvitis, 
451;  Follicular  Vulvitis,  454;  Erysipelas  of  Vulva,  455;  Phlegmonous  Vulvitis,  456;  Gan- 
grenous Vulvitis,  457;  Diphtheritic  Vulvitis,  457;  Eczema  of  Vulva,  457;  Intertrigo,  459; 
Herpes  of  Vulva,  461;  Prurigo  of  Vulva,  461;  Parasitic  Diseases  of  Vulva,  462;  Simple 
Vaginitis,  463;  Parasitic  Vaginitis,  466;  Diphtheritic  Vaginitis,  467;  Emphysematous  Vag- 
initis, 467;  Adhesive  Vaginitis,  468;  Simple  Ulcers,  470;  Chancroid,  472;  Syphilis,  479; 
Tuberculosis  of  Vulva,  484;  Tuberculosis  of  Vagina,  486;  Malignant  Disease  of  the  Vulva, 
487;  Malignant  Disease  of  the  Vagina,  488;  Ulcus  Rodens  Vulvae,  490;  Urethritis,  492;  Peri- 
urethral Abscess,  492;  Prolapse  of  Urethral  Mucosa,  494;  Urethral  Caruncle,  494;  Inflamma- 

13 


14  CONTENTS 

tion  of  the  Vulvo-vaginal  Gland,  496 ;  Abscess  of  Vulvo-vaginal  Gland,  496 ;  Sinus  of  Vulvo- 
vaginal Gland,  497;  Cyst  of  Vulvo-vaginal  Gland,  498;  Condylomata  of  Vulva,  499;  Cysts 
of  Vulva,  503;  Cysts  of  Vagina,  503;  Non-malignant  Tumors  of  Vulva,  505;  Non-malignant 
Tumor  of  Vagina,  505;  Stasis  Hypertrophy  of  Vulva,  505;  Pudendal  Hernia,  509;  Pudendal 
Hydrocele,  511;  Hematoma  of  Vulva,  512;  Varicose  Veins  of  Vulva,  514;  Injuries  of  External 
Genitals,  515;  Kraurosis  Vulvae,  516;  Pruritus  Vulvae,  518;  Hyperesthesia  of  the  Vaginal 
Entrance,  523 ;  Adhesions  of  Prepuce,  525 ;  Adhesions  of  Labia,  525. 

CHAPTER  V 

Relaxation  axd  Fistulae 

Points  in  Anatomy,  527;  Relaxation  of  the  Pelvic  Floor,  533;  Colpocele,  Rectocele, 
Cystocele,  558;  Recto-Vaginal  Fistula,  561;  Vesico-Vaginal  Fistula,  566. 

CHAPTER  VI 

Diseases  of  the  Uterus 

Points  in  Anatomy,  577;  Pathologic  Changes,  595;  Classification  of  Diseases,  596; 
Localization  of  Diseases,  597;  Erosion  of  Cervix,  598;  Ulcer  of  Cervix,  601;  Acute  Endo- 
cervicitis,  603;  Chronic  Endocervicitis,  606;  Laceration  of  Cervix  Uteri,  608;  Idiopathic 
Hypertrophy  of  Cervix,  624;  Cervical  Polypi,  625;  Hyperplasia  of  Endometrium,  628;  Acute 
Infected  Endometritis,  633 ;  Acute  Simple  Endometritis,  637 ;  Chronic  Endometritis,  638 ; 
Subinvolution  of  Uterus,  657 ;  Hyperinvolution  of  Uterus,  659 ;  Sclerosis  of  the  Uterus,  660 ; 
Tuberculosis  of  the  Uterus,  664;  Syphilis  of  the  Uterus,  666;  Echinococcus  Disease  .of 
Uterus,  666. 

CHAPTER  VII 

Displacement  of  the  Uterus 

Points  in  Anatomy,  669;  Backward  Displacement  of  the  Uterus,  671;  Prolapse  of  the 
Uterus,  696;  Other  Displacements  of  Uterus,  704. 


CHAPTER  VIII 

Non-Malignant  Tumors  of  Uterus 

Fibromyoma  of  the  Uterus,  704;  Symptoms  and  Signs,  723;  Pregnancy  and  Fibroid,  750; 
Lipoma  of  the  Uterus,  754. 

CHAPTER  IX 

Malignant  Disease  of  the  Uterus 

Carcinoma  of  the  Cervix  Uteri,  755;  Carcinoma  of  the  Corpus  Uteri,  789;  Sarcoma  of 
the  Uterus,  794. 

CHAPTER  X 

Pelvic  Inflammation 

Points -in  Anatomy,  799;  Fallopian  Tubes,  799;  Pelvic  Peritoneum,  804;  Pelvic  Connec- 
tive Tissue,  805;  Acute  Pelvic  Inflammation,  807;  Chronic  Pelvic  Inflammation,  833;  Differen- 
tial Diagnosis  of  Chronic  Pelvic  Inflammation,  848.    . 


CONTENTS  15 

CHAPTEE  XI 

Other  Affections 

Pelvic  Tuberculosis,  868;  Extrauterine  Pregnancy,  873;  Other  Pelvic  Disorders,  904; 
Hemorrhage,  904;  Fulminating  Pelvic  Edema,  905;  Tumors  of  Fallopian  Tubes,  907;  Varicose 
Veins  of  Broad  Ligament,  908;  Eehinocoecus  Disease  of  Pelvis,  909;  Pseudotuberculosis  of 
Peritoneum,  909. 

CHAPTER  XII 

Tumors  of  the  Ovary  and  Parovarium 

Points  in  Anatomy  and  Physiology,  910;  The  Ovary,  910;  The  Parovarium,  922;  Classifi- 
cation, 922;  Cystic  Tumors  of  the  Ovary,  923;  Solid  Tumors  of  the  Ovary,  953;  Tumors  of 
the  Parovarium,  955. 

CHAPTEE.  XIII 
Malformations 

Points  in  Development,  960 ;  Anomalies  of  Development,  964 ;  Imperforate  Hymen,  966 ; 
Atresia  of  Vagina,  966;  Double  Vagina,  967;  Malformations  of  the  Uterus,  968;  Pseudo- 
hermaphroditism, 969. 

CHAPTEE  XIV 

Disturbances  of  Function 

Points  in  Physiology  (Normal  Menstruation),  972;  Absence  of  Menstruation  (Amenor- 
rhea), 976;  Scanty  Menstruation,  988;  Excessive  Menstruation  (Menorrhagia),  988;  Painful 
Menstruation  (Dysmenorrhea),  993;  Intermenstrual  Pain,  1015;  Irregular  Menstruation,  1016; 
Precocious  Menstruation,  1016;  Vicarious  Menstruation,  1016;  Dyspareunia,  1017;  Sexual 
Impotence,  1019;  Sterility,  1020;  Leucorrhea,  1025;  Bloody  Discharge,  1030. 

CHAPTEE  XV 

The  Internal  Secretory  Glands  in  Eelation  to  Gynecology 

Historical  Facts,  1035;  Definition  of  Internal  Secretion,  1036;  Chemical  Nature  of 
Internal  Secretions,  1037;  Intergiandular  Eelation,  1038;  Influence  of  Individual  Endocrin 
Organs  on  the  Genital  Apparatus,  1040;  Gynecologic  Anomalies  Due  to  Disturbed  Endocrin 
Gland  Function,  1050;  Therapy,  1057. 

CHAPTEE  XVI 

Invasion  of  the  Peritoneal  Cavity 

Abdominal   Section,    1065 ;    Indications,    1066 ;    Contraindications,   1066 ;    Dangers,  1067 ; 

Preparations,    1067;    Eegular    Steps,    1073;    Special    Points,    1076;    Vaginal    Section,  1082; 

Advantages,  1082;  Disadvantages,  1083;  Selection  of  Cases,  1084;  Preparations,  1084;  Steps, 
1085;  Conservative  Surgery,  1085. 

CHAPTEE  XVII 

After-Treatment  in  Operath'e  Cases 
After-treatment  in  Abdominal  Section,  1089 ;  After-treatment  in  Vaginal  Operations,  1103. 

CHAPTEE  XVIII 

Medico-Legal  Points  in  Gynecology 
Eape,  1108;  Foreign  Bodies  Left  in  Abdomen,  1118;   Other  Conditions,  1124. 


ILLUSTRATIONS 


Relations  of  the  Pelvic  Organs 

FIG.  PAGE 

1.  Antero-posterior  section  of  pelvis   (Color  Plate) Frontispiece 

2.  Contour  and  measurements  of  two  models 34 

3.  Antero-posterior  section,  with  intestines  out 35 

4.  Posterior   view   of   pelvic    organs 36 

5.  Anterior    view    of    pelvic    organs 36 

6.  Relation  of  pelvic  organs  to  external  surface 37 

Gynecologic  Examination  Methods 

The  History 

7.  Indicating  general  pelvic  distress •.     .  38 

8.  Backache  from   pelvic  disease 39 

9.  Sacral   pain  from  pelvic  xlisease 39 

10.  Pain  in  right  tubo-ovarian  region 39 

11.  Pain  in  appendix  region 39 

12.  Pain  in  right  kidney  region,  laterally 40 

13.  Pain  in   right  kidney   region,   posteriorly 40 

14.  Gynecologic  history  card,  face 43 

15.  Gynecologic  history  card,  reverse 43 

Abdominal  Examination  . 

16.  Patient  arranged  for  abdominal  examination 45 

17.  Profile   of   normal   abdomen 45 

18.  Abdominal   surface   with   landmarks 47 

19.  Abdominal   surface   with   landmarks 48 

20.  Palpation  of  the  abdomen,  first  step 49 

21.  Palpation  of  the  abdomen,  second  step 49 

22.  Palpation  with   both  hands 49 

23.  Deep  palpation  with  both  hands 49 

24.  Piezometer 50 

25.  Abdominal   surface    divided    into    quadrants 50 

26.  Usual  anatomic  division  of   abdominal  surface 51 

27.  Division  of  abdominal  surface  with  circle 52 

28.  Regions,   by   division   with   circle 53 

29.  Various    areas    of    significant    point-tenderness 54 

30.  Point   for  kidney  tenderness,   laterally 55 

31.  Point   for   kidney   tenderness,   posteriorly 55 

32.  Relation  of  kidney  to  last  rib 55 

33.  Trying  for  a  fluid  wave  across  abdomen 55 


18  ILLUSTRATl  JNS 

FIG.  ^^GE 

34.  Differentiating  a  fat  wave  from  a  fluid  wave 57 

35.  Attempting  to  displace  a  mass  upward 58 

36.  Ordinary  percussion   of   abdomen 60 

37.  Deep    percussion    of    abdomen i      ....  60 

38.  Lines   for  mensuration   of   abdomen 61 

Examination  of  External  Genitals 

39.  Patient  arranged  for  examination  of  external  genitals  and  adjacent  structures     ...  63 

40.  Normal  external  genitals 64 

41.  Normal  external  genitals,  multipara 64 

42.  Pressing   pus    from   urethra 67 

43.  Appearance   of   pus   about  urethral   opening 67 

44.  Drop  of  pus  pressed  from  Skene's  gland 67 

45.  Vulvo-vaginal  gland '    ....  67 

46.  Appearance  of  pus   about  vulvo-vaginal  gland 68 

47.  Palpating  vulvo-vaginal   gland 68 

Vaginal  Examination    (Digital  Examination) 

48.  Position  of  fingers  for  vaginal  examination 70 

49.  Hand  gloved,  ready  for  examination 70 

50.  Position  of  thumb  and  outside  fingers 71 

51.  Bony  arch  above  vaginal  opening 74 

52.  Testing  the  pelvic  floor  with  one  finger 76 

53.  Testing  the  pelvic  floor  with  two  fingers 77 

54.  Showing  separation  of  examining  fingers 77 

55.  Another  method  of  testing  pelvic  floor 78 

56.  Palpating  rectum  through  vaginal  wall 79 

57.  Method   of   everting   anal   tissues ' 79 

58.  Showing  possible   eversion   in   some   cases 80 

V a gino- Abdominal  Examination    {Bimannal  Examination) 

59.  Bimanual  examination,  outside  Angers   folded  in  palm 84 

60.  Bimanual  examination,  outside  fingers  extended  in   gluteal   crease 84 

61.  Palpating    body    of    uterus 85 

62.  Depressing  abdominal  wall  too  close  to  pubes,  sectional  view 85 

63.  Depressing  wall  too  close  to  pubes,  outside  view 86 

64.  Depressing  wall   at   right   height 86 

65.  Bimanual  examination,  body  of  uterus  not  found  in  front .  87 

66.  Retroverted  uterus  found  behind 87 

67.  Retroflexed   uterus   found   behind 87 

68.  Palpating  sides  of  uterus  with  one  finger 89 

69.  Palpating  sides  of  uterus  with  two   fingers 89 

70.  Drawing  uterus  down,  to  aid  in  examinatioii 90 

71.  Invagination  of  perineum,  elbow  on  knee 92 

72.  Same  as  Fig.  75  in  bimanual  examination 93 

73.  Invagination  of  perineum,  ell)ow   against  iliac  crest 94 

74.  Palpation  of  lateral  regions,  first  step 94 

75.  Palpation  of  lateral  regions,   second  step 94 

76.  Showing  marked  depression  of  abdom=  -'         '  in  pelvic  palpation 95 


ILLUSTRATIONS  19 

FIG.  PAGE 

77.  Palpating    the    tubo-ovarian    region 96 

7&.  Palpating  the  left  tubo-ovai  :du  region     . 97 

79.  Palpating    the    right    tubo-ovarian    region 98 

80.  Determining  attachment  of  mass  to  uterus 99 

81.  Determining  attachment  to   posterior  part  of  uterus 100 

82.  Palpating  region   of   i-ight   ureter 101 

83.  Location  of  pelvic  nerve  roots 102 

84.  Palpating  pelvic  nerve  roots 102 

85.  Method  of  palpating  coccyx .  109 

Instrumental  Examination 

86.  Instruments   for   regular   speculum   examination 112 

87.  Bivalve  speculum  in  place 113 

88.  Gaylor  's    scissors 114 

89.  Introducing  the  bivalve   speculum,   first   step 115 

90.  Speculum   carried   half   way  in 115 

91.  Speculum  turned  and  carried  all  the  way  in 115 

92.  A,  Schultze  tampon;   B,  ordinary  tampon 117 

93.  Suction    bulb 117 

94.  Types  of  Sims'  speculum;  Graves'  speculum  changed  to  Sims'  type 117 

95.  Patient  in  Sims'  posture 120 

96.  View  from  above,   showing  Sims'  posture 120 

97.  Method  of  introducing  Sims'  speculum 121 

98.  Method   of   holding   Sims'    speculum 121 

99.  Cervix  uteri  brought  into  view 122 

100.  Instruments  for  exploration  of  interior  of  uterus 126 

101.  Eecto-abdominal   palpation 130 

102.  Method  of  palpating  the  pedicle  of  a  tumor 131 

103.  Eecto-vagino-abdominal   palpation 132 

104.  Glandular   hyperplasia   of   endometrium 133 

105.  Same,  sectioned  transversely 133 

106.  Interstitial  hyperplasia  of  endometrium 133 

107.  Same,  high  power 133 

108.  Adenocarcinoma    of    endometrium 135 

109.  Same,  high  power 135 

110.  Curettings,  incomplete  abortion 135 

111.  Same,  high  power 135 

112.  Exploration  of  interior  of  uterus  with  finger 137 

113.  Kitchen  table  arranged  for  gynecologic  examination 139 

114.  Simple   instrument  boiler 142 

115.  Small  instrument  and  dressing  sterilizer 142 

116.  Articles  needed  for  preparing  for  gynecologic  examination 143 

117.  Use  of  gloves  and  drop-bottle  for  liquid  soap 143 

118.  Wall  fixture  for  liquid  soap 144 

119.  Patient  arranged  in  bed  for  abdominal  examination 145 

120.  Patient  arranged  in  bed  for  vaginal  examination 146 

121.  Patient  arranged  in  bed  for  bimanual  examination 147 

122.  Showing  position  of  arms  for  accurate  deep  pelvic  palpation 148 

123.  Eegular  cross-bed  position 149 

124.  Partial  cross-bed  position 150 


20  ILLUSTRATIONS 

Gynecologic  Diagnosis 
Fronninence  of  Abdomen 

FIG.  PAGE 

125.  Obesity^  patient  lying  on  back 165 

126.  Testing  thickness  of  abdominal  wall,  first  step 165 

127.  Testing  thickness  of  abdominal  wall,   second  step 165 

128.  Obesity,  patient  standing 166 

129.  Obesity  mistaken  for  ovarian  tumor 166 

130.  Obesity    mistaken    for    pregnancy 166 

131.  Tumor  of  abdominal  wall 167 

132.  Small  umbilical  hernia 168 

133.  Large  umbilical  hernia 168 

134.  Contour  of  relaxed  abdominal  wall,  patient  recumbent .  169 

135.  Same  as   Fig.   134,  patient  standing 169 

136.  Space  between  separated  recti  muscles 170 

137.  Projection  of  abdominal  contents  between  separated  recti  muscles 170 

138.  Depression  of  wall  between  separated  recti  muscles 171 

139.  Tympanites  mistaken  for  pregnancy 171 

140.  Moderate    ascites   in    relaxed    abdomen 172 

141.  Marked    ascites,    showing    contour 173 

142.  Extreme  ascites,   showing  contour 173 

143.  Extreme   ascites,   with  pyramidal  contour 174 

144.  Extreme  ascites,  with  different  contour 174 

145.  Extreme  ascites,  view  from  in  front 175 

146.  Contour    of    abdomen    in    pregnancy 176 

147.  Contour  of  abdomen  in  case  of  distended  bladder 176 

148.  Case  of  ruptured  bladder,  section 176 

149.  Contour  of  abdomen  in  case  of  large  pelvic  cyst 177 

150.  Contour  of  abdomen  in  case  of  large  solid  tumor 177 

151.  Case  of   large   cystic  tumor 178 

152.  Case  of  extrophy  of  bladder 178 

153.  Contour  of  abdomen  in  case  of  retroperitoneal  tumor 179 

Tenderness  or  Mass  m  Aidomen 

154.  Eight  lower  abdomen,  important  areas  indicated 183 

155.  Point  to  seek  for  right  tubo-ovarian  tenderness 184 

156.  Point  to   seek  for  appendix  tenderness 184 

157.  Palpating  for  the   appendix 184 

158.  Another  method  of  palpating  for  the  appendix 184 

159.  Point  to  seek  for  tenderness  of  right  ureter 185 

160.  Left    lower    abdomen,    important    areas    indicated 186 

161.  Eegion  for  right  kidney  tenderness  laterally 187 

162.  Eegion  for  right  kidney  tenderness  posteriorly 187 

163.  Eight  upper  abdomen,  important  organs  indicated 188 

164.  Site  for  gall-bladder  tenderness   or  mass 189 

165.  Showing  the  direction  of  growth  of  various  pelvic  and  abdominal  tumors     ....  192 

Area  of  Dullness  in  Abdomen 

166.  Indicating  area  of  dullness  from  distended  bladder 193 

167.  Indicating  area  of  dullness  from  enlarged  iiterus 193 


ILLUSTRATIONS  21 

FIG.  .  P^GE 

168.  Indicating  area  of  dullness  from  very  large  central  pelvic  mass .  194 

169.  Indicating  dullness  from  enlarged  liver 195 

170.  Indicating   dullness  from   enlarged   spleen 195 

171.  Area  of  dullness  in  moderate  ascites,  patient  on  back 196 

172.  Eelation  of  fluid  to  intestines  in  ascites 196 

173.  Eelation  of  mass  to  intestines  in  tumor 196 

174.  Showing  gravitation  of  ascitic  fluid  to  lower  side 196 

175.  Indicating  dullness  in  moderate  ascites,  patient  on  side 197 

176.  Indicating   dullness  in  moderate  ascites,  patient   standing 198 

177.  Area  of  resonance  in  case  of  extreme  ascites,  patient  on  back 199 

178.  Same  as  Fig.   177,  patient   standing 200 

179.  Same  as  Fig.  177,  the  two  resonant  areas  contrasted 201 

180.  Dullness  in  case  of  ascites  and  tumor,  patient  on  back 202 

181.  Same  as  Fig.  180,  patient  standing 203 

182.  Same  as  Fig.  180,  two  areas  of  dullness  contrasted 204 

183.  Indicating  dullness  in  large  tubo-ovarian  mass 204 

184.  Indicating  dullness  in  largQ  appendiceal  mass 204 

185.  Indicating  irregularity  of   dullness  from  uterine  flbromyoma '  .  205 

186.  Indicating  regularity  of  dullness  from  large  ovarian  cyst 205 

187.  Area  of  dullness  in  case  of  retroperitoneal  growth r     •     •  206 

188.  Indicating  dullness  in  kidney  tumor,  without  inflation  of  colon 207 

189.  Same  as  Fig,  188,  with  inflation  of  colon 207 

190.  Kidney  tumor  removed  in  case  of  Fig.  188 208 

Changes  About  External  Genitals 

191.  External   genitals   of   virgin 209 

192.  External    genitals    diagrammatic 209 

193.  Various   forms   of   hymen 210 

194.  Various   forms  of   hymen 210 

195.  Various   forms  of   hymen 210 

19'6.  External  genitals  of  married  women 210 

197.  External  genitals,  parts  prepared  for  operation 211 

198.  External  genitals  with  some  perineal  laceration 212 

199.  Follicular  vulvitis 217 

200.  Kraurosis  vulvae 218 

201.  Chancroidal  ulcers  of  vulva 219 

202.  Tubercular  ulcer  of  vulva 220 

203.  Epithelioma  of  right  labium 221 

204.  Beginning  epithelioma  of   labium 221 

205.  Epithelioma  of  clitoris 221 

206.  Case  of  adherent  prepuce 223 

207.  Same   as   Fig.    206,   after   treatment 223 

208.  Adherent  labia  minora 22o 

209.  Imperforate    hymen 223 

210.  Hematocolpos 224 

211.  Distention  of  uterus  and  tubes  from  imperforate  hymen 224 

212.  External  genitals  in  case  of  absence  of  vagina 224 

213.  Double  vagina 225 

214.  Same  as  Fig  213,  each  vagina  spread  open 225 

215.  Complete   laceration   of   perineum 225 


22  ILLUSTRATIONS 

FIG.  P^GE 

216.  Complete   laceration    of    perineum 226 

217.  Separation  of  sphincter  ends  in  old  complete  laceration 226 

218.  Central  perforation  of  perineum  by  child's  head 227 

219.  Laceration    of    hymen   from    rape 227 

220.  Complete  laceration  of  perineum   from  rape 227 

221.  Laceration  of  perineum,  with  resulting  fistula,  from  violent  coitus     ..'....  228 

222.  Old  laceration  of  pelvic  floor  from  labor 229 

223.  Moderate   cystocele   and  rectocele 230 

224.  Same  as  Fig.  223,  showing  section 230 

225.  Large   cystocele 231 

226.  Testing  for  cystocele  with  sound  in  bladder 232 

227.  Small  rectocele 232 

228.  Large  rectocele 233 

229.  230.  Differentiating  between   rectocele .  and   colpocele     . 233 

231.  Hematoma  of  vulva 234 

232.  Stasis-hypertrophy    of    labia    minora 234 

233.  234.  Stasis-hypertrophy   of   vulva " 235 

235.  Stasis-hypertrophy   and    edema 236 

236.  Marked   stasis-hypertrophy 236 

237.  Stasis-hypertrophy  with  causative   ulceration 236 

238.  Elephantiasis  of  vulva 236 

239.  Varicose   veins    of   vulva 237 

240.  Small  masses  of  condylomata 237 

241.  Vulva    covered   with   massed    condylomata .     .  237 

242.  Syphilitic   condylomata    about    vulva 238 

243.  Syphilitic    condylomata,    flat   variety 238 

244.  Syphilitic  condylomata,  pointed  vai'iety 239 

245.  Abscess  of  vulvo-vaginal  gland 240 

246.  Abscess  of  vulvo-vaginal  gland 241 

247.  Cyst  of  vulvo-vaginal  gland 241 

248.  Hypertrophy    of    labia    minora 242 

249.  Enormous  hypertrophy  of  labia  minora   (Hottentot  apron) 242 

250.  Hypertrophy  of  clitoris 243 

251.  Carcinoma    of    labium,    beginning     . 243 

252.  Carcinoma  of  labium,  later  stage 244 

253.  Carcinoma  of   labium,   still  later   stage 244 

254.  Carcinoma  of  vulvo-vaginal  gland 245 

255.  Sarcoma   of   labium     , 246 

256.  Small   fibroma   of   labium 246 

257.  Large  fibroma  of   labium 246 

258.  Small  cysts  of  labium ■ 247 

259.  Large   cyst    of   labium 247 

260.  Large   cyst    of   labium 248 

261.  Cyst    of    clitoris 248 

262.  Inguinal  hernia,  becoming  pudendal 249 

263.  Vaginal   hernia,   becoming    pudendal 249 

264.  Prolapse  of  urethral  mucosa 250 

265.  Urethral  caruncle 250 

266.  Suburethral   abscess 251 

267.  Exploring    suburethral    abscess-sinus 252 

268.  Prolapse   of   uterus,    showing   various    stages 252 


ILLUSTRATIONS  23 

FIG.  PAGE 

269.  Prolapse  of  uterus,  cervix  at  vestibule 252 

270.  Prolapse  of  uterus,  uterus   half   out 253 

271.  Complete  prolapse  of  uterus '. 254 

272.  Prolapse  of  uterus,  bladder  not  prolapsed 254 

273.  Prolapse  of  uterus  and  bladder 255 

274.  Testing  for  prolapse  of  bladder  with  sound 255 

275.  Prolapse  of  uterus  in  nullipara 256 

276.  Prolapse  of  uterus  in  virgin 256 

277.  Bimanual   examination   in  prolapsus   uteri 257 

278.  Three  portions  of  the  cervix  uteri 257 

279.  Hypertrophy  of  infravaginal  portion  of  cervix,  diagrammatic 257 

280.  Case  of  hypertrophy  of  infravaginal  portion  of  cervix 258 

281.  Hypertrophy  of  supravaginal  portion  of  cervix 258 

282.  Hypertrophy  of  intermediate  portion  of  cervix 25S 

283.  Peculiar  hypertrophy  of  cervix 258 

284.  Pedieulated  fibroid  tumor   of  uterus 259 

285.  Complete  inversion  of  uterus,  with  placenta  attached 260 

286.  Small  cyst   of   vaginal   wall 260 

287.  Medium-sized  cyst  of  vaginal  wall 261 

Changes  Found  hy  Vaginal  Examination 

288.  Small  uterine  fibroid  projecting  into  vagina 263 

289.  Large  uterine  fibroid  projecting  into  vagina 263 

290.  Differentiating  a  pedieulated  fibroid  with  sound 263 

291.  Sarcoma  of  uterus  projecting  into  vagina 264 

292.  Grape-like  sarcoma  of  cervix,  forming  mass  in  vagina 264 

293.  Inverted  uterus,  forming  mass  in  vagina 265 

294-302.  Differentiating  inversion  from   fibroid 267 

303,  304.  Diagnosis    of   inversion    of   uterus 267 

305.  Sounding  uterus  in  diagnosis  of  inversion 268 

306.  Partial  inversion   caused   by   fibroid 268 

307.  Small  cysts  of  vaginal  wall 268 

308.  Anterior  vaginal  hernia 268 

309.  310.  Relation  of   cervix  uteri  to  examining  finger 270 

311.  Anteflexion    of    cervix    uteri 271 

312.  Eversion  of  cervical  mucosa  from  inflammation     , 272 

313-318.  Lacerations  of  cervix  uteri 273 

319.  Softening  of  cervix  in  early  pregnancy 273 

320.  Section  of  cervix  in  late  pregnancy,  showing  cervix  still  of  full  length 273 

321.  Carcinomatous  nodule  in  cervix 274 

322.  Nodule  due  to  cyst  of  cervix 274 

Changes  in  Corpus  Uteri 

323.  Retrodisplacement  of  uterus,  showing  first,  second,  and  third  degrees 276 

324.  Uterus  displaced  by  full  bladder ■ 276 

325.  Uterus  displaced  by  inflammatory  mass 276 

326.  Uterus    displaced    by    tumor     .  ■ 277 

327.  Uterus   displaced  by   adhesions 277 

328.  Uterus  enlarged  from  early  pregnancy 278 

329.  Early  pregnancy   with  slight   retrodisplacement 279 


24  ILLUSTRATIONS 

FIG.  PAGE 

330.  Early  pregnancy  with  marked  retrodisplacement 279 

331.  Pregnant  uterus  sectioned,  showing  cause  of  Hegar's  sign 280 

332.  Explaining  Hegar  's  sign 281 

333.  Palpating  for  Hegar's  sign,  uterus  in  front "  .  281 

334.  Palpating  for  Hegar's  sign,  uterus  behind 281 

335.  Small  fibroid  nodules  in  uterus 282 

336.  Larger  fibroid  nodules   in   uterus '   .     .     .     .  282 

337.  Fibroid  nodules  in  uterus .  282 

338.  Single  fibroid  causing  slight  enlargement  of  corpus  uteri 283 

339.  Enlargement  of  corpus  uteri  from  pregnancy,  about  four  months 283 

340.  Enlargement  of  corpus  uteri  from  pregnancy,  about  four  months ,     .  284 

341.  Pregnancy    of   about   five   months 284 

342.  Pregnancy  at  full  term 284 

343.  Height  of  fundus  uteri  at  different  weeks  of  pregnancy 285 

344-346.  Irregular  shapes  that  pregnant  uteri  may  present .  285 

347.  Interstitial    pregnancy 286 

348.  Pregnancy  in  right  half  of  septate  uterus 286 

349.  Uterus  enlarged  by  large  single  soft  fibroid 287 

350.  Uterus  symmetrically  enlarged  by  fibroids 288 

351.  Subperitoneal   fibroids 288 

352.  Single  large  fibroid  choking  pelvis 289 

353.  Large  fibroids  filling  pelvis  and  lower  abdomen 289 

354.  Uterus   enlarged   from    carcinoma 289 

355.  Large  fibroid  and  early  pregnancy 289 

356.  Small  fibroid  and  late  pregnancy 290 

357.  Uterus  distended  with  menstrual  blood 290 

358.  Uterus  enlarged  by  collection  of  pus  and  gas 290 

Mass  in  Pelvis  or  Lower  Ahdovien 

359.  Three  areas  in  the  pelvis 291 

360.  Parametrial  inflammation  contrasted  with  ischiorectal  inflammation 291 

361.  Mass  in  right  ureter 292 

362.  Abscess  in   broad  ligament 293 

363.  Hematoma   in   broad    ligament 293 

364.  Cyst    in   broad   ligament 294 

365.  Ovarian   cyst  beside  uterus 295 

366.  Hematometra  in  rudimentary  horn  of  uterus 296 

367.  Thickened  tube  and  ovary  prolapsed  into  cul-de-sac 297 

368.  Fibroid  back  of  cervix  uteri 298 

369.  Fibroid   above  retrodisplaced  uterus 298 

370.  Abscess  behind  uterus 299 

371.  Blood-mass  behind  uterus 299 

372.  Ovarian   cyst  behind  uterus 300 

373.  Testing  mobility  of  mass  behind  uterus 301 

374.  Fibroid   in   front   of   uterus 303 

375.  Bladder  tumor  in  front  of  uterus 304 

376.  Tuberculosis  of  bladder,  forming  mass  in  front  of  uterus .  304 

377.  Inflammatory  exudate   filling   pelvis 305 

378.  Inflammatory   roof   above   vagina 305 

379.  Pelvis   filled  with  bony   tumor 306 


ILLUSTRATIONS  25 

FIG.  I'AGE 

380.  Pelvis  filled  with   ovarian  cyst 306 

381.  Salpingitis  nodosa 308 

382.  Thrombosis  of  veins  of  broad  ligament ;     .     .  308 

383.  Tubal  pregnancy  in  right   side ^ 309 

384.  Pregnancy  in  rudimentary  horn  of  uterus 310 

385.  Pregnancy  in  rudimentary  horn  of  uterus 311 

386.  Various   locations   of   appendix 312 

387.  Various   locations   of   cecum 313 

388.  Displaced  right  kidney 314 

389.  Palpation  of  movable  kidney,  first  step 315 

390.  Palpation  of  movable  kidney,  second  step 315 

391.  Double  pyosalpinx  with  adhesions 316 

392.  Double  pyosalpinx  without  adhesions 316 

393.  Pyosalpinx  with  extensive  adhesions 317 

394.  Right    hydrosalpinx .     .     .  • 318 

395.  Small   ovarian  cyst   of   right   side ...■..,  318 

396.  Graafian  follicle  cysts  which  have  become  intraligamentary 319 

397.  Large  pelvic  mass  formed  by  uterine  fibroids  and  carcinoma    ■ 321 

398.  Extrauterine  pregnancy,  advanced 322 

399.  Extrauterine    pregnancy    with   lithopedion 322 

400.  Lithopedion  removed 322 

401.  Left  kidney  displaced  into  pelvis 323 

402.  Large  cystic  fibroid 323 

403.  Ovarian  cyst  with  long  pedicle •     '     '  ^^^ 

404.  Large  dermoid  cyst 325 

405.  Ascites    and   uterine    fibroid 326 

Changes  Seen  Through  Speculum 

406.  Primary  cancer  of  vaginal  wall 329 

407.  Secondary  cancer  of  vaginal  wall 330 

408-410.  Varieties   of  normal  cervix •.    .     331 

411.  Senile  cervix 331 

412.  Discharge   from   cervix 331 

413.  Laceration  and  erosion  of  cervix 331 

414.  Erosion  and  cysts  of  cervix 331 

415.  Lacerations    and   erosions    of    cervix 33L 

416.  Lacerations    and   erosions    of    cervix 333 

417.  418.  Testing    for    laceration    of    cervix 334 

419.  Beginning    epithelioma    of  .cervix 334 

420.  Beginning  carcinoma  of  cervix     . ■  "^34 

421.  Epithelioma,    cervix    destroyed 335 

422.  Epithelioma,    cervix   destroyed    and   surface   infolded 336 

423.  Epithelioma  of  cervix,  appearing  as  a  papillary  growth 337 

424.  Showing  usual  origin  of  reflex  pains  in  the  various  regions 343 

Gynecologic  Treatment 

425.  Patient  arranged  for  long,  hot  vaginal  douche 360 

426.  Preparation    of    vaginal    tampons ^"^ 

427.  Tampon-capsules ^'" 


26  ILLUSTRATIONS 

FIG.  PAGE 

428.  Hodge   pessary  and   modifications 372 

429.  Pessary  in   place .  373 

430.  431.  Introducing   pessary 378 

432,  433.  Introducing    pessary ...  379 

434.  Introducing  pessary 380 

435.  Introducing  pessary 381 

436.  Flexible  ring  pessary,  inflated  ring  pessary,  and  disk  pessary 384 

437.  Menge  pessary 385 

438.  Gehrung    pessary ,  386 

439.  Introducing    Gehrung    pessary 386 

440.  Introducing    Gehrung    pessary 388 

441.  introducing    Gehrung    pessary 388 

442.  Hewitt  pessary 389 

443.  Applicators   for  intrauterine   treatment 395 

444.  Knee-chest     posture 414 

445.  Knee-chest  posture  with  pelvic  organs   outlined     . 415 

446.  Knee-chest  posture  with  patient  draped  for  treatment     . 415 

Additional  Illustrations  for  Various  Diseases 

447.  448.  Anatomy   of   Skene's   glands 424 

449,  450.  Anatomy   of  Skene's   glands 425 

451.  Veins    of    external    genitals 426 

452.  Arteries   and   nerves   of   external   genitals 426 

453.  Cross   section  of   vagina 428 

454.  Gonococci  stained  in  pus 437 

455.  Gonococci  much  enlarged  to  show  form     .     .     .' 437 

456.  Pediculus     pubis 462 

457.  Thrush   fungus 466 

458.  Adhesive  vaginitis  . 469 

459.  Sarcoma  of  vagina  in  child ■ 489 

460.  Same,  high  power •  489 

461.  Scattered    condylomata    of    vulva 500 

462.  Large    masses   of    condylomata 500 

463.  Pointed   condyloma,    cross   section 501 

464.  Fibroma   of   vagina 501 

465.  Excision    of    external    genitals      . ' 507 

466.  Excision  of  varicose  veins   of   vulva 514 

467.  Sectional  view  of  pelvic  floor,  diagrammatic 528 

468.  Superficial  structures  of  pelvic  floor 529 

469.  Levator  ani  muscles •  530 

470.  Eecto-vesical   fascia 530 

471-473.  Pelvic  sling '    ...  531 

474.  Pelvic   floor   from    above 532 

475.  Deep  lateral  laceration  of  pelvic  sling  on  each  side 536 

476.  Median  laceration  into  rectum,  but  not  into  sling 536 

477.  Instruments   for  repair   of   pelvic   floor 543 

478.  Eecent  lacerations  from  labor 544 

479.  480.  Regular   repair    of    pelvic   floor ' 547 

481,  482.  Eegular    repair    of   pelvic   floor 548 

483,  484.  Regular   repair    of   pelvic   floor 549 


ILLUSTRATIONS  27 

FIG.  PAGE 

485,  486.  Regular    i-epair    of    pelvic   floor 550 

487.  Old   laceration    of    pelvic    floor 551 

488.  Emmet's  operation — lines  of  tension 552 

489.  Emmet 's  operation — denuding 552 

490.  Emmet's    operation — general    scheme    of    suturing 553 

491.  492.  Repair  of  complete  tear  of  j)erineum r     •     •  554 

493,  494.  Repair  of  complete  tear  of  perineum 555 

495,  496.  Repair    of    cystocele 559 

497,  498.  Repair   of   cystocele 561 

499.  Fistulae   of   genital   tract 562 

500.  Regular   operation   for   vesico-vaginal    fistula 571 

501.  502.  Flap  operation  for  vesico-vaginal  fistula 572 

503.  Anterior  view  of  uterus 577 

504.  Anterior-posterior    section    of   uterus 577 

505.  Uterus,  Fallopian  tube,  and  ovary 578 

506.  Reconstruction  of  uterus,  showing  shape  of  cavity 579 

507.  Uterus  and  appendages  of  young  child 579 

508.  Uterus,  tube,   and  ovary  of  fourteen-year-old   girl 579 

509.  Uterus,  tube,  and  ovary  of  twenty-year-old  multipara 579 

510.  Pelvic  contents   of  large  fetus ' 580 

511.  Comparisons  of  nulliparous  uterus  with  niultiparous  uterus     .     .     .     ". 580 

512.  Relation  of  uterus  to  vagina  and  bladder 581 

513.  Endometrium    of    infant 581 

514.  Uterine  wall  of   child 583 

515.  Same,  high  power 583 

516.  Normal  endometrium 584 

517.  Gland  and  stroma  of  endometrium 585 

518.  Menstruating  endometrium,  early  stage 586 

519.  Same,  later  stage 586 

520.  Senile   endometrium 587 

521.  Cervical  gland 588 

5iii!.  Cervical  gland,  cross  section 588 

523.  Blood  supply  of  uterus 589 

524.  Blood    supply    of    uterus 590 

525.  Lymphatics    of   uterus 591 

526.  Distribution  of  uterine  lymphatics  to  various  groups  of  glands 592 

527.  Ligaments  of  uterus 594 

528.  Section  through  an  erosion  of  cervix 599 

529.  Cervical   erosion 600 

530.  Cervical    ulcer 602 

531.  Same,  high  power 602 

532.  Lacerated   cervix   with   erosion 610 

533.  Instruments   for  repair   of   cervix 615 

534.  Areas  for  denudation  for  repair  of  cervix 616 

535.  Areas  of  denudation 616 

536.  Incision  through  scar-tissue  at  the  angles 616 

537.  Denudation  completed  and  sutures  passed  in  right  side 618 

538.  Sutures   tied 619 

539.  Section    through    cystic    cervix 621 

540.  Cystic  cervix 621 

541.  Area  for  amputation  in  cystic  cervix 622 


28  ILLUSTRATIONS 

PIG.  PAGE 

542.  Line  of  excision  and  method  of  suturing  in  partial  amputation  of  cervix     ....  622 

543.  Partial  amputation  of  cervix 623 

544.  Partial    amputation    completed 624 

545-547.  Regular  amputation  of  cervix     . 626 

548.  Regular   amputation  of   cervix 627 

549.  Polypi  of   cervix 627 

550.  Fibrous  cervical  polypi,  cross  section 628 

551.  Normal   uterus  and  endometrium 639 

552.  553.  Polypoid    endometritis 641 

554.  Glandular  hyperplasia   of   endometrium .  642 

555.  Same,  high  power 642 

556.  Polypoid  formation  in  hyperlastie  endometrium 643 

557.  Instruments  for  curettage 644 

558.  Kitchen   table   arranged   for    curettage 645 

559.  Patient  in  position  at  end  of  operating  table 646 

560.  561.  Cleansing  vagina  after  patient  is  anesthetized 647 

562.  Self -retaining  speculum  introduced 648 

563.  Sterile    sheet    in    place 648 

564.  Introducing  large  dilator 649 

565.  Large  dilator  in  place 649 

566.  Introducing   curet 650 

567.  Method   of   holding   curet 651 

568.  Returning  uterus  to  its  normal  position  after  curettage 651 

569.  Putting  in   vaginal   packing 652 

570-573.  Dressing  after  curettage 653 

574.  T-bandage 654 

575.  Section  of  endometrium  thirteen  days  after  curettage     . 655 

576.  Section  of  endometrium  thirty-one  days  after  curettage 655 

577.  Section  of  endometrium  three  months  after  curettage 656 

578.  Section  of  endometrium  fifty-three  days  after  application  of  caustic 656 

579.  Fibrosis    of    uterus 662 

580.  Normal  uterine  wall 662 

581.  Tuberculous   endometrium 663 

582.  Section  of  pelvis  showing  normal  position  of  uterus 669 

583.  View  from   above,   showing  position    of   uterus 670 

584.  Bimanual    replacement    of    uterus 676 

585.  586.  Bimanual    replacement    of    uterus 677 

587.  Bimanual    replacement    of    uterus 678 

588.  Bimanual    replacement    of    uterus 679 

589.  Bimanual   replacement    of    uterus 680 

590.  Puncturing    tenaculum    forceps 692 

591.  Transplantation   of  round  ligaments 693 

592.  Transplantation   of  round  ligaments 694 

593.  Transplantation   of   round   ligaments 695 

594.  Uterine    fibromyoma 698 

595.  Adenomyoma •  698 

596.  Interstitial  fibroid 705 

597.  Fibrous    capsule    of    myoma 705 

598.  Same,     high    power 705 

599.  Same,  higher  power 705 

600.  601.  Multiple    fibromyomata 706 


ILLUSTRATIONS  29 

FIG.  PAGE 

602.  Multiple   fibromjomata 707 

603.  Multiple  fibromyomata 708 

604.  Encapsulated  myoma,  low  power 708 

605.  Submucous  fibroid 709 

606.  Photomicrograph — ^uterine  wall  fibroid  pressing   against  endometrium 710 

607.  Polypoid  type  of   submucous  fibroid 711 

608.  Diffuse  adenomyoma  of  uterus 712 

609.  Hyaline    degeneration    of    fibroma         712 

610.  Same,     high     power 712 

611.  Cystic  cavity  in  uterine  fibromyoma 713 

612.  Large    cystic   fibromyoma 714 

613.  Large     subserous     fibroid 715 

614.  Necrosis  of  part  of   intraligamentary  fibromyoma 716 

615.  Suppurating    fibromyoma 716 

616.  Necrosis   of   whole   fibromyoma 717 

617.  Perforation  of  uterus  by  necrotic  fibromyoma         718 

618.  Section   through   uterine    sarcoma 719 

619.  Photomicrograph  of  sarcoma  of  uterus ' 720 

620.  Sarcoma  developed  in  cervical  stump  after  supravaginal  hysterectomy  for  fibromyoma  721 

621.  Section  of   original   fibromyoma,   showing   sarcomatous   areas 722 

622.  Displacement  of  bladder  by  large  fibromyoma 723 

623.  Lipoma    of    uterine    wall 753 

624.  Early   cervical    carcinoma 756 

625.  Microscopic  picture  of  squamous-cell   carcinoma   of   cervix 756 

626.  Same,  higher  power 756 

627.  Carcinomatous    plug   in    cervical    gland 757 

628.  Adenocarcinoma  of  cervix 757 

629.  Same,  high  power 757 

630.  Advanced  cervical  carcinoma 758 

631.  Cervical  carcinoma,  papillary  growth 759 

632.  Epithelioma  of   cervix,  more   advanced 760 

633.  Advanced  adenocarcinoma  of  cervix 761 

634.  Epithelioma  of  cervix,  in  late  stage 762 

635.  Epithelioma  of  cervix  associated  with  fibromyoma  of  corpus  uteri 763 

636.  Same  as  Fig.  635,  section  of  uterus  and  fibroid .  764 

637.  Damage  to  ureters  and  kidneys  by  advanced  cancer  of  cervix 765 

638.  Necessary  line  of  excision  in  radical  operation  for  cancer  of  cervix  uteri     ....  777 

639.  Cancerous  uterus   removed  by  Wertheim's  radical  operation 782 

640.  Beginning    carcinoma    of    corpus    uteri 790 

641.  Corpus   carcinoma,   early   stage 790 

642.  Corpus  carcinoma,  advanced  stage 790 

643.  Adenocarcinoma  of  corpus  uteri,  microscopic  section,  low  power 791 

644.  Same,     high     power 791 

645.  Same,     high     power 791 

646.  Carcinoma   of   corpus  uteri   in    advanced    stage 792 

647.  Chorioepithelioma   of   uterus '^^3 

648.  Chorioepithelioma   of   uterus "^"^ 

649.  Same,  microscopic   section '•^"^ 

650.  Same,  higher  power '"'^ 

651.  Beginning   sarcoma   of   corpus   uteri • 79o 

652.  Slight  enlargement  of  corpus  uteri  from  sarcoma 796 


30  ILLUSTRATIONS 

FIG.  PAGE 

653.  Advanced   sarcoma    of    corpus    uteri 796 

654.  Sarcoma  of   endometrium 797 

655.  Sarcoma  of  endometrium,  microscopic  section 797 

656.  Same,     high     power 797 

657.  Sarcoma  of  endometrium,  entire  uterus 798 

658.  Section  of  genital  tract,  showing  continuous  opening  into  peritoneal  cavity     .     .     .  800 
659-661.  Cross  sections  through  normal  Fallopian  tube 801 

662.  Cross  section  through  normal  Fallopian  tube 802 

663.  Cross  section  through  normal  Fallopian  tube 803 

664.  Connective    tissue    of    pelvis 806 

665.  Thrombo-phlebitis .809 

666.  Instruments  for  opening  pelvic  abscess 814 

667.  Opening   pelvic   abscess — incision   of   vaginal   wall 815 

668.  Opening  pelvic  abscess — blunt  dissection  through  connective  tissue 815 

669.  Opening   pelvic    abscess — puncturing    abscess    wall 816 

670.  Opening  pelvic  abscess — drainage  tube  in  place 816 

671.  Drainage  tube  with  cross-piece 818 

672.  Drainage  tube  with  cross-piece,  another  method 819 

673.  Vaginal   section   for   acute   pelvic   inflammation — sectional   view 822 

674.  Vaginal   section  for   acute  pelvic   inflammation — view   from   above 828 

675.  676.  Proctoclysis    apparatus 829 

677.  Chronic    salpingitis,    mild 835 

678.  Salpingitis,    with   exudate 836 

679.  Chronic   salpingitis,    cross    section 837 

680.  Normal    tube,    cross    section 837 

681.  Chronic   salpingitis,  low  power 837 

682.  Same,  higher  power 837 

683.  Pyosalpinx,  wdth  and  without  surrounding  exudate 838 

684.  Section  through  large   pyosalpinx 839 

685.  Specimen.     Large  pyosalpinx 839 

686.  Diffuse     pelvic     suppuration 840 

687.  Ovarian  abscess  and  tubo-ovarian   abscess 841 

688.  Hydrosalpinx      . 842 

689.  Hydrosalpinx.       Microscopic    section 843 

690.  Same,  higher  power 843 

691.  Nodular    salpingitis 844 

692.  Pelvic    adhesions 845 

693.  Pelvic  cellulitis    (parametritis) 845 

694.  Various  situations  in  which  a  parametritic  mass  may  be  found 846 

695.  Cystic   ovary 847 

696.  Direction  of   extension   of  gonococcal  infection 857 

697.  Direction   of   extension   of   streptococcal   infection 861 

698.  Pelvic   tuberculosis,   peritoneal   form 869 

699.  Pelvic  tuberculosis,  tubal  form 870 

700.  Giant   cells   in   tubal    tuberculosis 871 

701.  Same,  higher  power 871 

702.  Situation  of  ovum  in  various  forms  of  tubal  pregnancy 875 

703.  Pelvic   hematocele •     •  876 

704.  Blood   mass   from   repeated    small   hemorrhages 877 

705.  Free  intraperitoneal  rupture  of  tube 878 

706.  Free    intraperitoneal    hemorrhage 878 


ILLUSTRATIONS  31 

FIG.  PAGE 

707.  Tubal  abortion — tube  distended .     . 879 

708.  Tubal  abortion — extruded   clots   and   embryo ,  879 

709.  Early   tubal   pregnancy "        .     .  879 

710.  Advanced    tubal    pregnancy 880 

711.  Same,  microscopic  section 881 

712.  Pelvic   hematoma 881 

713.  Mother  and  child  in  case  of  extrauterine  pregnancy  carried  to  near  term     ....  882 
714;  Sarcoma  of  Fallopian  tube,  low  power 907 

715.  Same,  high  power 907 

716.  Treatment  for  varicose  veins  of  broad  ligament 908 

717.  Showing  attacliment  of  ovary  to  broad  ligament 910 

718.  Section  of  ovary,  showing  hilum  and  medullary  portion  and  cortical  portion     .     .  910 

719.  Graafian     follicle 911 

720.  Graafian  follicle  and  ovarian  stroma 912 

721.  Development  of  the  ovary 913 

722.  Ovarian  stroma  with  immature  follicles 913 

723.  Corpus   luteum 914 

724.  Corpus  luteum,  very  large 914 

725.  Corpus  luteum,  showing  interior  arrangement 914 

726.  Ovai'ian  stroma,  corpus  luteum 915 

727.  Lutein   cells 915 

728.  Corpus   luteurii,   high    power 915 

729.  Corpus     albicans 915 

730.  Corpus     albicans      ...  - 916 

731.  Scars  in  ovary 917 

732.  Parovarium   and    paroo^jhoron,    embryonic 917 

733.  Parovarium,   with    surrounding    structures 921 

734.  Follicular    cysts    of    the    ovary 924 

735.  Follicular    cyst    in    ovary 924 

736.  Corpus     luteum     cysts 925 

737.  Lutein  cells,  the  distinguishing  feature  in  the  wall  of  corpus  luteum  cysts     .     .     ,  926 

738.  Cyst  involving  part  of  ovary 927 

739.  Cyst   involving   entire   ovary 927 

740.  Tubo-ovarian   cyst .  928 

741.  Patient    with    large    ovarian    cyst 928 

742.  Pseudomucinous  cyst,  with  jelly-like  contents 929 

743.  Pseudomucinous   cyst,   sliowing   secondary   growths 930 

744.  Lining  of  pseudomucinous  cyst 931 

745.  Same,  high  power 931 

746.  Lining  cells  of  pseudomucinous  cyst  and  of  serous  cyst  contrasted 932 

747.  Small   serous   cyst,   showing   internal   papillary  projections 932 

748.  Larger    serous    cyst 933 

749.  Serous  cyst,  with  secondary  growths  projecting  through  wall 933 

750.  Bilateral   papillary   ovarian   cystoma 935 

751.  Dermoid  cyst  of  ovary 936 

752.  Dermoid  cyst  of  ovary 937 

753.  Hair   switch    from    ovarian    dermoid 937 

754.  Balls  of  sebaceous  material  from  dermoid  cyst 937 

755.  Ovarian   dermoid • 938 

756.  Same,  microscopic  section 940 

757.  Ovarian    cyst,   with   torsion    of    pedicle 946 


32  ILLUSTRATIONS 

FIG.  PAGE 

758.  Ovarian    fibroma ' 947 

759.  Same,  microscopic  section 948 

760.  Same,  higher  power 948 

761.  Ovarian   carcinoma,   low  power 948 

762.  Same,  high  power 948 

763.  Solid,   medullary   ovarian    carcinoma 949 

764.  Same,   cross   section 950 

765.  Same,  microscopic  section 950 

766.  Primary  solid  ovarian  carcinoma,  low  power 951 

767.  Same,  high  power 951 

768.  Krukenberg  tumor  of  ovary ' .    ■ 952 

769.  Same    specimen    on    cross    section 952 

770.  Same,  microscopic  section 953 

771.  Distribution  of  metastases  in  the  case  of  Krukenberg  tumor 953 

772.  Metastatic  ovarian  sarcoma,  microscopic  section 954 

773.  Same,   higher  power 954 

774.  Small  parovarian  cyst 956 

775.  Parovarian     cyst 956 

776.  Wall  of  parovarian  cyst,  microscopic  section , 957 

777.  Large  parovarian  cyst ,i 958 

778.  Development  of  pelvic  organs,  indifferent  stage 961 

779.  Development   of   pelvic   organs,   female 961 

780.  Development  of  pelvic  organs,  male 962 

781.  Development    and    malformations 963 

782.  Development  of  external  genitals 964 

783.  Pseudohermaphrodite,    external   view 970 

784.  Pseudohermaphrodite,   explanatory   section 970 

785.  Stem  pessaries • ^^^^ 

786.  Dudley   operation 1010 

787.  Dudley   operation •  .     .     .     .  1011 

788.  Dudley   operation ■ lOH 

789.  Suturing  in  front  of  cervix •     •  1013 

790.  Dressing  abdominal  incision 1074 

791.  Conservative    surgery   of   ovary    and   tube 1087 

792.  Strapping    abdomen   after   removal    of    sutures 1092 

793.  Cutting  adhesive  straps  for  inspection  of  healed  incision 1093 

794.  Scar     exposed 1094: 

795.  Tray  of   articles  for   care  of   drainage   tube 1096 

796.  Syringe  and  catheter  for  rapid  removal  of  large  quantity  of  fluid  from  tube     .     .  1097 

797.  After-treatment   in   vaginal   operations — pitcher   douche 1104 

798.  After-treatment  in  vaginal  operations— vulvar   dressing 1105 

799.  Catheterization— keeping    the   labia    apart 1106 

800.  Catheterization — grasping  the  catheter  some  distance  from  the  point 1100 


DISEASES  OF  WOMEN 


CHAPTER  I 

GYNECOLOGIC  EXAMINATION  METHODS 

The  physician  Avho  wishes  to  do  accurate  work  in  diagnosis  must  be  in  pos- 
session of  certain  facts,  as  follows: 

Knowledge  of  the  anatomy  and  physiology  of  the  organs  involved. 
Reliable  history  and  examination  of  the  patient. 
Knowledge  of  the  diseases  to  which  the  parts  are  liable. 

The  essential  organs  in  the  group  of  structures  involved  in  gynecologic* 
diseases  are  shown  in  Figs.  1,  3,  4,  5  and  6.     They  are  as  follows: 

1.  The  ovaries,  in  which  the  ova  are  formed. 

2.  The  Fallopian  tubes,  which  conduct  the  ova  from  the  ovaries  to 

the  uterus. 

3.  The  uterus,  which  receives  and  nourishes  the  fertilized  ovum  and 

expels  the  fetus  at  term. 

4.  The  vagina,  which  is  the  connecting  link  between  the  uterus  and 

the  outside  world. 

There  are  also  several  accessory  structures — namelj^,  the  external  gen- 
itals, the  perineum,  the  pelvic  floor,  the  pelvic  peritoneum  and  the  pelvic 
comiective  tissue. 

The  gross  anatomy  of  these  organs  and  the  prominent  facts  in  their 
physiology  are  sufficiently  known  to  you,  from  general  anatomic  and  physi- 
ologic study,  to  permit  immediate  consideration  of  the  methods  of  obtain- 
ing the  facts  on  which  the  diagnosis  may  be  based. 

HISTORY 

When  called  tt)  see  a  patient  with  pelvic  disease,  the  first  thing  to  do  is 
to  obtain  what  information  the  patient  can  give  concerning  her  trouble. 
This  information,  obtained  from  the  patient  or  her  friends,  is  designated  the 


*As  to  the  pronunciation  of  "gynecology,"  the  weight  of  authority  is  decidedly  in  favor  of  soft  g, 
short  y  and  the  accent  on  the  third  syllable — jin  e  kol'  o  je  (Webster's  Unabridged  Dictionary,  Century 
Dictionary,  Standard  Dictionary,  Gould's  Medical  Dictionary,  Keating's  Medical  Dictionary).  A  few 
authorities   differ,  some  favoring  soft  g  and   long  y,   and  others  favoring  hard  g  and  long  y. 

33 


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Fig.  2.  A.  Exact  Contour  and  Measurements  of  the  woman  selected  for  Fig.  1.  B.  Exact  Con- 
tour and  Measurements  of  another  model,  presenting  a  more  pronounced  lumbar  and  abdominal  curve. 
The   small   squares   represent  one-inch   squares   at   life   size.      (R.    Walter   Mills.) 

(A)  Artist's  model,  aged  28,  mother  of  two  children  (6  and  8  years  old  respectively),  has  worn 
corset  practically  none,  is  in  good  health  and  fairly  muscular.  Height  5  ft.  7  in.,  weight  140  lb.,  bust 
measure  36  in.,  waist  27  in.  (2  in.  above  umbilicus),  circumference  at  umbilicus  30  in.,  hips  39  in., 
thigh  22^  in.  (2  in.  below  gluteal  crease),  antero-posterior  diameter  of  body  at  waist  6J4  in.,  antero- 
posterior diameter  of  thigh  (2  in.  below  gluteal  crease)  6^  in.  The  other  data  are  given  on  the  out- 
line. To  conform  to  the  so-called  "perfect  form"  the  hips  should  be  a  trifle  larger  and  the  weight  some- 
what  more. 

(B)  Young  woman,  aged  27,  never  pregnant,  has  worn  corset  very  little,  is  in  good  health  and 
muscular.  Height  5  ft.  4  in.,  weight  114  lb.,  bust  measure  32  in.,  waist  24  in.  (2  in.  above  umbilicus), 
hips  38  m.,  thigh  22  in.  (2  in.  below  gluteal  crease),  anlero-rosterior  diameter  of  body  at  waist  dV^  in., 
antero-posterior°diameter  of  thigh  (2  inches  below  gluteal  crease)  (>Vt  in.  The  other  data  are  given  on 
the   outline.      The  lumbar   and   abdominal   curves   are   more   pronounced    than   in   A. 

The  numerous  exact  measurements  given  in  Fig.  2  constitute  valuable  data  to  guide  in  medical 
drawings    of   this    character. 


TAKING    THE    HISTORY 


35 


history,  and  should  include  facts  covering  all  the  important  points.  The 
following  outline  indicates  the  information  to  be  obtained,  and  also  pre- 
sents a  convenient  order  in  which  to  question  the  patient  and  record  the 
systematic  history: 

Preliminary  Questioning — To  ascertain  the  principal  complaint   (character,  location, 
duration,  etc.)  and  put  the  patient  at  ease. 


Fig.   3.     Antero-posterior   Section  of  Pelvis.      Showing  left  half  of  body,   with  intestines   removed. 

(Kelly — Operative    Gynecology.) 


History  Record 

Social  Items — Xame,  address,  age,  married,  occupation. 

Previous  Health — General  health,  abdominal  inflammation,  nervous  disturbances, 
operations,  etc. 

Pregnancies — ConJinements,  miscarriages,  sterility. 

Menstrual  History — Beginning,  regularity,  duration,  amount,  pain,  last  two  menstrua- 
tions. 


36  GYNECOLOGIC   EXAMINATION    METHODS 

Beginning  of  Present  TrouWe — When,   how,  cause. 

Principal  Symptoms — Character,  time  of  onset,  duration  of  each. 

Disability — Confinement  to  bed,  interference  with  work,  etc. 

Complications — Character,  onset,  duration. 

ramily  History — In  special  cases,  nervous  disturbance,  tuberculosis,  etc. 

Previous  Treatment — Different  kinds,  results. 

Summary  of  chief  symptoms  demanding  relief. 


Fig.    4.      View   of   Pelvic   Organs   from   Behind.      (Tlickinson— American    Textbook    of   Obstetrics.) 


Fig.   3.     Pelvic  Organs  from  in   Front.      (Dickinson— ^mericaw   Textbook   of  Obstetrics.) 

Preliminary  Questioning-.     Of  what  symptoms  does  the  patient  complain? 
A  question  directed  to  bring  out  this  information  will  at   once   enlist  the 


TAKING    THE    HISTORY 


37 


patient's  interest  and  relieve  any  temporary  embarrassment  she  may  feel. 
The  prominent  symptoms  are  soon  given,  and  serve  to  indicate  lines  of 
special  inquiry  when  taking  the  systematic  history  of  the  case.  The  system- 
atic inquiry  is  begun  at  some  convenient  point  in  the  patient's  narrative.  - 

Social  Items.  It  is  well  to  put  down  at  this  time  the  facts  not  strictly 
medical,  for  if  postponed  some  of  them  are  liable  to  be  overlooked  alto- 
gether. Record  accurately  the  patient's  name,  address,  age,  whether  married 
or  single;  and  if  single,  the  occupation;  if  married,  how  long.  If  she  has 
been  married  more  than  once,  or  if  a  widow  or  if  living  apart  from  her  hus- 
band, she  will  probably  mention  the  fact  and  also  any  correlated  facts  bear- 


Fig.    6.     Relation    of    the    Pelvic    Organs   to    the    External    Surface    of   the   body. 
American  Textbook  of  Obstetrics.) 


(Dickinson- 


ing  on  the  present  disturbance.  In  some  cases  it  may  be  advisable,  for  busi- 
ness reasons,  to  note  other  items  of  information — for  example,  the  husband's 
occupation  and  business  address. 

Previous  Health.  Ascertain  whether  or  not  the  patient  Avas  Avell  and 
strong  before  the  beginning  of  the  present  trouble.  Any  serious  illness, 
whether  connected  with  the  pelvic  organs  or  not,  should  be  inquired  into. 
It  may  be  an  important  factor  in  the  origin  of  the  present  disturbance  or  it 
may  point  to  some  complication  which  must  be  taken  into  consideration  in  the 
treatment.  Of  particular  importance  are  serious  nervous  disturbances,  attacks 
of  abdominal  inflammation,  and  operations. 


3g  GYNECOLOGIC    EXAMINATION    METHODS 

Pregnancies.  Labors.  Has  the  patient  had  children?  If  so,  how  many 
and  when?  Was  there  serious  trouble  during  any  labor,  or  during  any  preg- 
nancy, or  afterward?  Make  particular  inquiry  as  to  whether  the  labor  was 
so  severe  that  instruments  had  to  be  used,  or  whether  the  labor  was  followed 
by  indications  of  sepsis  or  of  laceration  of  the  pelvic  floor  or  cervix  uteri.  If 
after  any  labor  the  patient  was  sick  in  bed  for  two  or  three  weeks,  with  pain 
in  the  lower  abdomen  and  fever,  she  probably  had  sepsis  in  some  form,  the 
usual  form  being  septic  endometritis.  Another  very  common  history  of  mild 
sepsis  is  that  the  patient  gets  up  as  usual,  but  does  not  feel  strong  and  after 
a  few  days  takes  a  ''backset"  and  returns  to  bed  or  drags  about  the  house  with 
soreness  in  the  lower  abdomen,  some  fever,  and  marked  weakness.  Of  course, 
delays  in  convalescence  after  labor  may  be  caused  by  complications  outside 
the  genital  tract,  but  generally  they  are  due  to  some  trouble  in  the  genital 


Fig.    7.     Indicating   General    Pelvic    Distress.      This    distress    may    be    due    to    bladder    or    uterine 
or    tubal    or    ovarian    disease    on    one    or    both    sides. 


tract,  such  as  infection  of  the  uterus  or  subinvolution  of  the  uterus  or  lacera- 
tion of  the  pelvic  floor. 

Miscarriages.  Have  there  been  any  miscarriages?  If  so,  how  many  and 
when  and  at  what  stage  of  pregnancy  did  each  occur?  What  was  the  cause 
of  each  miscarriage  ?  Did  it  follow  some  accident,  or  was  it  due  to  some  acute 
disease  such  as  typhoid  fever  or  pneumonia?  If  there  have  been  repeated 
miscarriages,  inquire  carefully  and  circumspectly  as  to  evidences  of  syphilis. 
Have  the  miscarriages  been  brought  about  intentionally  (criminal  abortion)— 
if  so,  in  what  way?  AVas  each  miscarriage  complete  and  no  trouble  follow- 
ing? When  incomplete,  part  of  the  fetal  membranes  are  retained  in  the 
uterus  and  cause  a  persistent  bloody  discharge.    Sepsis  also  may  occur. 

Sterility.     When  the  patient  has  been  married  a  long  time  and  there  has 


TAKING    THE    HISTORY 


39 


been  no  pregnancy,  it  is  Avell  to  inquire  as  to  why  there  has  been  no  pregnancy, 
and  if  treatment  has  been  undertaken  for  the  sterility. 

Menstrual  History.     How  old  was  the  patient  when  she  began  to  men- 


Fig.    8.     Backache   from   pelvic   disease.      Indicating        Fig.    9.     Backache    from   pelvic   disease.      Indicating 
pain  in  the  central  lumbar   region.  pain    extending   down    over    the    sacrum. 


Fig.   10.     Indicating     pain      in      right     tubo-ovarian        Fig.   11.     Indicating  pain   in  the  appendiceal  region. 
region. 


struate?  Has  the  menstruation  been  regular  and  of  proper  duration  and 
amount,  and  free  from  severe  pain?  If  there  has  been  menstrual  disturbance — 
for  example,  absence  of  menses,  or  excessive  menstruation  or  irregular  men- 
struation or  intermenstrual  bleeding- — ascertain  the  duration  and  severity  of 


40 


GYNECOLOGIC   EXAMINATION    METHODS 


each.  Invariably  ascertain  the  date  and  duration  of  the  last  two  menstrua- 
tions that  pregnancy  may  be  excluded. 

Beginning'  of  Present  Trouble.  How  long  has  the  patient  been  sick? 
Ascertain  accurately  when  the  present  trouble  began.  If  it  has  been  of  long 
duration,  pass  back  of  the  several  exacerbations  and  get  the  approximate 
date  of  the  first  acute  attack  or  first  appearance  of  decided  symptoms.  What 
were  these  first  symptoms?  How  severe  were  they?  "What  was  done  for 
them?  What  caused  the  trouble  at  that  time?  Had  there  been  a  severe  sick 
spell  or  an  injury  of  any  kind?  Had  there  been  a  labor  or  miscarriage  or 
menstrual  disturbance  or  recent  marriage  or  extra  work  or  anything  that 
might  have  acted  as  a  cause  ? 

Character  and  Duration  of  Principal  Symptoms.  Get  an  account  of  the 
present  trouble  from  the  day  it  began  down  through  the  important  changes 


Fig.    12.     Indicating  pain  in  the   region   of  the   right 
kidney. 


Fig.  13.  Another  common  way  of  indicating  the 
dragging  pain  that  accompanies  disease  and  displace- 
ment of  the  kidney. 


to  the  date  of  consultation.  This  does  not  mean  to  waste  time  with  a  mass  of 
unnecessary  detail  but  to  ascertain,  by  well  directed  inquiries,  the  order  of 
development  and  duration  of  the  principal  symptoms,  such  as  pain,  fever, 
swelling,  discharge,  etc. 

Locate  definitely  the  site  of  the  pain  or  tenderness  or  other  distress  com- 
plained of.  Is  it  in  the  tubal  region  or  appendix  region  or  over  the  uterus  or 
about  the  ureter  or  kidney  ?  Have  the  patient  point  out  the  exact  location  of 
the  pain.  Figs.  7  to  13  indicate  the  location  of  the  pain  in  various  affections. 
This  definite  localization  helps  to  clarify  the  situation  and  makes  the  patient 
more  careful  and  reliable  in  her  statements.  Of  course,  no  diagnosis  should  be 
attempted  from  such  necessarily  uncertain  localization  by  the  patient.     This 


TAKING    THE   HISTORY  41 

simply  indicates  what  group  of  organs  are  probably  affected  and  enables  the 
physician  to  question  the  patient  more  definitely  and  accurately  before  begin- 
ning the  physical  examination. 

Ascertain  the  frequency  and  duration  of  the  exacerbations  of  the  disease. 
Has  the  trouble  been  getting  worse  gradually  and  continuously,  or  have  there 
been  exacerbations  followed  by  remissions,  with  partial  or  complete  disappear- 
ance of  the  symptoms'? 

Disability.  How  much  of  the  time  has  the  patient  been  confined  to  bed? 
If  able  to  be  up  and  about  part  of  the  time  or  all  the  time,  how  much  work  or 
walking  or  shopping  has  she  been  able  to  do?  Is  the  patient  engaged  in  any 
work  aside  from  her  household  duties  ?  If  so,  what  is  it  and  has  it  any  bearing 
on  the  origin  or  continuation  of  the  present  trouble  ?  Does  she  do  any  of  her 
own  housework?  If  so,  how  much?  Is  it  executed  with  facility,  as  when  she 
was  well,  or  is  there  pain  and  disability  ?  Ascertain  carefully  the  character  of 
the  distress  associated  with  the  work.  What  time  of  day  does  it  come  on, 
where  is  it  located,  is  it  a  sharp  pain  or  a  dull  aching  or  a  dragging-weight  and 
pressure?  What  posture  aggravates  or  relieves  it,  does  it  necessitate  lying 
down,  does  it  recur  soon  after  rising,  is  it  present  every  day,  does  it  vary  from 
week  to  week  or  month  to  month?  Ascertain  also  the  effect  on  the  general 
health  and  nutrition.  How  much  has  the  patient  lost  in  weight  or  has  she 
gained  ? 

Complications.  Inquire  concerning  complications  or  associated  diseases. 
Frequently  there  are  complicating  bladder  or  rectal  or  other  local  disturb- 
ances, and  the  extent  of  these  should  be  determined.  Inquiry  should  be 
made,  also,  for  symptoms  of  diseases  of  remote  organs,  either  complications 
of  the  pelvic  trouble  or  intercurrent  diseases.  All  the  vital  organs  of  the 
patient  must  be  considered  in  estimating  the  influence  of  the  pelvic  disease 
and  in  forming  the  plan  of  treatment  for  it.  Many  serious  mistakes  in  diag- 
nosis and  in  treatment  have  occurred  because  the  physician  permitted  some 
marked  local  lesion  to  obscure  his  vision  of  the  whole  patient. 

In  addition  to  the  heart,  lungs,  kidneys,  and  digestive  tract,  the  condition 
of  the  patient's  blood,  as  indicated  by  her  color,  and  the  condition  of  the 
nervous  system,  as  indicated  by  her  appearance  and  actions,  should  be  con- 
sidered; and  if  there  is  evidence  of  disease  in  any  direction,  further  investiga- 
tion should  be  carried  out. 

Family  History.  In  some  cases  certain  items  of  the  family  history  are 
important,  particularly  nervous  disturbances,  tuberculosis  and  cancer — though 
the  influence  of  family  tendency  to  cancer  has  been  much  exaggerated.  Other 
family  items  of  importance  in  gynecologic  cases  are  hemophilia  and  men- 
strual peculiarities,  especially  very  late  or  very  early  menopause. 

Previous  Treatment.  Question  the  patient  as  to  the  character  and  dura- 
tion of  the  previous  treatment  and  its  apparent  effect.  Was  it  internal  treat- 
ment or  local  treatment  at  home  (douches,  vaginal  suppositories,  or  tablets 


42  -  GYXECOLOGIC    EXAMINATION    METHODS 

or  tampon-capsules;  or  local  treatment  at  office  (vaginal  applications,  tam- 
pons, intrauterine  treatment)  or  operation  (curetting,  repair  of  pelvic  floor 
or  cervix,  vaginal  section  or  abdominal  section). 

Summary.  After  completing  the  history  and  before  beginning  the  exam- 
ination, fix  in  mind  the  chief  symptoms  for  which  the  patient  seeks  relief. 
Keep  these  in  mind  while  making  the  examination  and  endeavor  to  find  the 
lesion  or  condition  that  causes  each  of  them.  These  symptoms  serve  to  indi- 
cate the  directions  for  special  investigation.  The  diagnosis  should  be  made, 
to  a  considerable  extent,  as  the  examination  progresses.  Before  finishing  the 
examination,  you  should  have  formed  an  opinion  as  to  whether  or  not  you 
have  found  the  cause  or  causes  of  the  symptoms  which  brought  the  patient 
to  you. 

Keep  a  Record 

A  short  record,  giving  in  a  systematic  way  the  principal  facts  of  a  case, 
may  be  made  quickly  and  more  than  repays  for  the  time  consumed.  And  the 
principal  advantage  is  not  the  permanent  record  it  gives  for  reference  after 
some  years,  though  that  is  important,  especially  to  the  teacher,  but  the  fact 
that  it  systematizes  and  steadies  and  improves  the  physician's  work  day  by 
day.  Such  an  account  of  the  case  in  black  and  white,  referred  to  frequently 
as  the  patient  returns  for  treatment,  is  a  constant  stimulus  to  accurate  diag- 
nosis and  a  constant  help  in  the  treatment,  particularly  if  the  case  is  a  long 
continued  one.  Again,  in  court  a  physician  is  supposed  to  have  some  record 
of  his  work.  You  may  at  any  time  be  called  upon  to  testify  as  to  the  exact 
findings  in  the  case  of  some  patient  whom  you  saw  one  or  two  or  three  years 
before. 

The  record  should  embody  the  important  facts  in  the  history,  in  the  ex- 
amination findings,  in  the  treatment  given,  and  in  the  subseciuent  progress  of 
the  case.  The  great  drawback  to  records  is  the  time  required  to  make  them. 
In  order  to  make  them  at  all,  the  physician  must  have  some  arrangement  by 
which  the  record  may  be  made  in  a  very  few  minutes.  This  is  where  printed 
forms  are  advantageous.  On  a  printed  form  the  physician  may,  in  a  few 
minutes,  put  down  the  notes  necessary  to  make  an  accurate  account  of  the 
case. 

Record  cards,  printed  as  desired,  and  ai-ranged  as  a  card  index,  constitute 
a  very  convenient  record  system  for  the  busy  practitioner,  and  at  a  moderate 
cost.  The  author  uses  -l:x6  cards,  printed  on  one  side  for  the  prmcipal  record 
(Fig.  14),  the  back  of  the  card  (Fig.  15)  being  used  for  extra  notes.  When 
more  space  is  required  blank  cards  are  attached  as  needed.  When  it  is  desired 
to  have  a  sketch  of  the  condition,  a  small  outline  of  the  pelvis  or  abdomen  is 
stamped  at  some  clear  space  on  the  card  (with  the  required  rubber  stamp, 
of  which  any  desired  kind  may  be  obtained  at  small  expense)  and  the  tumor 
or  inflammatory  mass  or  displaced  organ  is  then  draAvn  in.     The  author  uses 


TAKING    THE    HISTORY 


43 


two  kinds  of  form  cards — identical  in  size  but  differing  in  color.  For  the 
regular  gynecologic  history  and  examination,  a  white  card  is  used.  If  the 
patient  is  subjected  to  operation,  a  buff  ''operation  card"  is  added.     If  one 


DATE 

NAME 

ADDRESS 

oe. 

PREVIOUS   H. 

CONFIN. 

MUC 

OEG. 

o    > 

P4IN 

WITH  ILL.  REO. 

PlIM 

LAST  MENSTR. 

PRESENT   ILLNESS 

EXAM.  INO  DIAG. 

Fig.    14. 

Gynecologic  History  Card. 

The  original    card  is   6  in. 

wide   and   4   in. 

high. 

OUTLINE   OF    TR. 


Fig.    IS.      Reverse    side    of    History    Card. 


44  GYNECOLOGIC   EXAMINATION    METHODS 

does  not  wish  to  invest  in  specially  prepared  cards  and  holders,  a  start  may  be 
made  with  some  blank  cards  of  the  desired  size,  arranged  upright  in  the 
ordinary  desk  drawer. 

Is  a  Pelvic  Examination  Required? 

After  obtaining  all  the  information  the  patient  can  give  concerning  her 
illness,  the  next  step  is  to  make  the  physical  examination,  provided  there  are 
symptoms  making  such  an  examination  necessary. 

In  the  case  of  a  virgin,  pelvic  examination  is  rarely  indicated  until  after 
general  therapeutic  measures  have  been  tried  and  have  failed  to  give  relief. 
Occasionally  a  young  woman  or  a  girl  will  present  such  serious  symptoms  that 
an  examination  is  indicated  at  the  first  visit,  but  such  cases  are  extremely 
rare. 

On  the  other  hand,  in  the  case  of  a  majrried  woman,  if  decided  pelvic 
symptoms  are  present,  an  examination  should,  as  a  rule,  be  made  at  once, 
particularly  if  there  has  been  previous  treatment  without  satisfactory  result. 

If  the  patient  is  menstruating,  the  examination  is  of  course  postponed, 
unless  the  symptoms  are  serious  and  urgent.  A  non-menstrual  bloody  discharge 
is  not  a  contraindication  to  examination,  but  rather  an  additional  indication 
for  it. 

If  the  patient  is  extremely  anxious  to  avoid  the  examination,  treatment 
without  it  may  be  tried  for  a  while  in  a  suitable  case,  even  though  immediate 
examination  seems  decidedly  preferable. 

When  a  girl  is  examined,  her  mother  or  some  other  relative  should  be 
present. 

PHYSICAL  EXAMINATION 

The  order  of  examination  which  the  author  finds  most  convenient,  when 
the  patient  can  be  placed  on  the  table,  is  as  follows: 
Abdominal  Examination. 

Inspection  of  External  Genitals,  Meatus,  Perineum,  etc. 
Vaginal  Examination  (Digital). 
Vagino-abdominal  Examination  (Bimanual). 
Instrumental  Examination. 

Exceptionally 

Examination  of  Eectum. 

Pelvic  Examination  under  Anesthesia. 

Examination  of  Bladder. 

When  the  patient  is  seen  at  home,  the  order  of  examination  is  more  fre- 
quently abdominal,  vaginal,  vagino-abdominal  and,  when  indicated,  a  digital 
examination  per  rectum.  Inspection  of  the  external  genitals  and  the  specu- 
lum examination  are  usually  not  required  in  such  a  case. 


PHYSICAL   EXAMINATION 


45 


HoAvever,  if  there  are  symptoms  pointing  to  disease  of  the  external  gen- 
itals, the  parts  should  of  course  be  inspected.  Also,  in  any  case,  if  it  is  thought 
that  information  of  value  may  be  obtained  by  the  speculum  examination,  that 
procedure  should  be  carried  out. 


Fig.    16.      Patient    on    table    and    arranged    for    abdominal    examination. 


Fig.    17.      Profile    of    Normal    Abdomen.      Patient    arranged    for    abdominal    examination. 


46  GYNECOLOGIC    EXAMINATION    METHODS 

ABDOMINAL  EXAMINATION 

Have  the  patient  lie  near  tlie  edge  of  the  bed  or  table,  in  a  comfortable 
position,  with  the  head  slightly  raised  on  a  pillow  and  the  knees  drawn  np 
sufficiently  to  relax  the  abdominal  muscles  (Figs.  16,  17,  119). 

The  abdomen  is  subject  to: 

Inspection — Contour,  Color,  Eruption,  Striae,  Scars. 

Palpation — Tension,  Tenderness,  Mass,  Fluctuation,  Fluid  Wave.  Fat 

Wave,  Fetal  Movement,  Uterine  Contraction,  Friction  Rub. 
Percussion — Area  of  Dullness. 

Auscultation — Fetal  Heart  Sounds,  Vascular  Murmur. 
Menstruation — For  accurate  comparison. 

INSPECTION  OF  ABDOMEN 

Contour,  Movement,  Color,  Eruption,  Striae,  Scars 

The  principal  thing  to  determine  by  inspection  is  contour.  Determine  also 
the  other  items  mentioned — movement  of  wall,  color,  eruption,  striae,  scars — 
but  usually  they  are  of  secondary  importance.  As  to  contour,  there  may  exist, 
one  of  several  conditions,  as  follows: 

The  smooth,  moderately  full  contour  of  the  normal  abdomen  (Figs. 

17,  18,  19). 
The  flat,  sunken  abdomen  of  wasting  disease,  with  empty  intestines. 
A  swollen,  prominent  abdomen  (Figs.  139  to  151). 
The  significance  of  prominence  of  the  abdomen  is  taken  up  in  detail  in 
the  chapter  on  Diagnosis  (Chapter  ii). 

PALPATION  OF  ABDOMEN 

Tension,  Tenderness,  Mass,  Fluctuation,  Fluid  Wave,  Fat  Wave,  Fetal  Move- 
ment, Uterine  Contraction,  Friction  Rub. 

Tension  and  Tenderness 

As  to  tension,  we  determine  whether  the  wall  is  soft  and  easily  depressed, 
or  is  firm  and  resisting  from  muscular  tension.  The  latter  condition  may  be 
due  to  nervousness  or  fright,  the  patient  fearing  that  the  examination  will 
cause  pain,  or  it  may  be  due  to  genuine  tenderness  from  inflammation  or  irri- 
tation beneath  the  wall,  as  in  peritonitis  or  intraperitoneal  hemorrhage. 

The  best  way  to  begin  palpation  is  to  place  the  palmar  surface  of  the 
whole  hand  flat  on  the  abdominal  wall  (Fig.  20).  Hold  it  there  perfectly 
quiet  for  a  moment,  that  the  patient  may  see  that  you  are  not  going  to  cause 
pain.  Then,  as  the  muscular  tension  relaxes,  depress  the  wall  carefully  with 
the  fingers  (Fig.  21)  in  various  directions  and  situations  as  the  hand  is  moved 


PHYSICAL    EXAMINATION 


47 


about  over  the  surface.  Begin  the  movement  of  the  hand  gradually,  almost 
imperceptibly  at  first,  perhaps  at  the  same  time  directing  the  patient's  atten- 
tion away  by  a  question  or  two.  When  the  patient's  attention  is  fixed  on  the 
palpating  hands,  there  is  likely  to  be  troublesome  tension  of  the  wall.  As  the 
examination  proceeds,  deep  palpation  is  made  in  various  parts  of  the  abdo- 
men in  order  to  exclude  disease  in  the  various  regions.     Palpation  with  both 


S 


<  ,^/ 


I 


Fig.    18.      The   abdominal   surface   with  the   rib   margins   and   the   iliac    crests   outlined. 


hands  (Fig.  22)  assists  much  in  determining  the  character  and  consistency 
of  the  tissues  between  them  and  under  them,  particularly  when  the  abdomen 
is  rather  full.  If  a  resisting  area  is  found,  work  the  fingers  around  it,  de- 
pressing the  wall  and  examining  all  portions  of  it  (Fig.  23).  The  palpation 
should  always  be  made  gently,  for,  if  the  manipulations  cause  pain  or  frighten 
the  patient,  the  wall  is  immediately  made  tense  and  then  no  satisfactory  ex- 
amination is  possible. 


48 


GYNECOLOGIC   EXAMINATION    METHODS 


In  a  case  of  suspected  appendicitis  or  one  sided  inflammation,  the  difference 
in  tension  of  the  abdominal  wall  on  the  two  sides  is  of  diagnostic  importance. 
Ordinarily  the  difference  of  tension  may  be  determined  with  sufficient  accuracy 
by  palpation.  If  desired,  the  piezometer  (Fig.  24)  devised  by  Kelly  (Johns 
Hopkins  Hospital  Bulletin,  Sept.,  1904)  may  be  used. 


Fig.    19.     Another    abdominal    surface,    with    the    ribs    and    crests    outlined.      This    patient    is    rather    stout. 
Notice  how  much  the  landmarks  differ  from  those  in  Fig.  18. 

Having  determined  the  general  tension  and  tenderness,  search  is  made  for 
local  tenderness.  The  exact  location  of  the  tenderness  should  be  carefully 
determined,  and  also  whether  it  is  circumscribed  to  that  area  or  extends  to 
other  areas.     When  the  area  of  tenderness  has  been  accurately  located,  we 


PHYSICAL   EXAMINATION 


49 


knoAv  what  organs  are  likely  to  be  affected,  and  the  further  differentiation 
between  affections  of  those  organs  may  be  proceeded  with. 

Regions  of  the  Abdomen.     For  convenience  in  designating  the  location  of 


Fig.     20.      Palpation    of    the    abdomen.       First    step.         Fig.    21.      Palpation.      Depressing    the   wall    with   the 
Hand   flat   on   abdominal   surface.  fingers    of    one    hand,    in    various    situations. 


Fig.   22.      Palpation  with  both  hands. 


Fig.   23.      Deep   Palpation   with   both   hands. 


50 


GYNECOLOGIC   EXAMINATION    METHODS 


tenderness  or  of  a  mass,  the  abdomen  is  divided  into  regions.  There  are  many 
methods  of  division.  A  simple  and  useful  one  is  the  division  of  the  surface 
into  quadrants  by  an  imaginary  horizontal  line  passing  through  the  umbili- 
cus and  a  vertical  line  through  the  same  point  (Fig.  25). 


Fig.   24.     Piezometer,   for  measuring  the   tenderness  to  pressure  and   the   muscular   resistance. 


Fig.    25.       The    abdominal    surface    divided    into    Quadrants. 


This  is  very  convenient  for  designating  in  a  general  Avay  the  location  of 
large  masses,  but  it  is  not  sufficiently  definite  for  the  accurate  localization  of 
small  masses  or  points  of  tenderness. 


PHYSICAL    EXAMINATION 


51 


For  the  more  definite  localization,  the  time  honored  division  into  squares, 
by  tAvo  vertical  and  two  horizontal  lines  (Fig.  26),  is  the  one  generally  fol- 
lowed in  anatomic  and  diagnostic  works.  However,  as  a  practical  working 
division  for  diagnostic  and  teaching  purposes,  this  has  been  found  decidedly 
inconvenient  and  unsatisfactory,  as  is  attested  by  the  many  attempts  of 
clinicians  to  devise  a  simple  method  of  dividing  the  surface  and  of  designating 
the  various  regions. 


Fig.  26.  The  usual  anatomic  division  of  the  abdomen  into  nine  regions  by  two  transver'=e  lines 
and  two  vertical  lines.  The  upper  transverse  line  is  at  the  level  of  the  cartilages  of  the  ninth  ribs,  and 
the  lower  with  the  highest  points  of  the  iliac  crests.  The  two  parallel  vertical  lines  pass  through  the 
cartilages    of   the    eighth    ribs    and    the   middle   of    Poupart's   ligaments. 

Failing  to  find  a  method  of  division  that  was  satisfactory  to  the  author,  he 
devised  that  shown  in  Fig.  27,  which,  so  far  as  he  knows,  is  original.  The  only 
lines  not  marked  by  natural  landmarks  are  a  circle  with  a  two-inch  radius 
about  the  umbilicus  and  a  short  straight  line  extending  horizontally  for  two 
inches  from  each  side  of  the  circle. 

The  regions  are  designated  as  right  lower,  left  lower,  central  lower,  right 
upper,  left  upper,  central  upper,  umbilical,  and  right  and  left  lumbar  (Fig. 
28).    This  method  of  division  is  simple,  and  the  names  are  easily  remembered 


52 


GYNECOLOGIC    EXAMIXATIOX    METHODS 


and  are  self-explanatory.  In  fact,  these  designations  are  the  ones  commonly 
used  in  conversation  among  physicians  in  describing  the  location  of  a  mass 
or  area  of  tenderness.  For  example,  we  speak  of  tenderness  in  the  right  lower 
region  of  the  abdomen,  or,  more  briefly,  in  the  "right  lower  abdomen,"  or  in 
the  "left  lower  abdomen,"  or  in  the  "right  upper  abdomen,"  etc. 

Within  each  of  these  principal  regions  there  are  one  or  more  points  which 
are  of  special  interest.  The  special  interest  attaches  to  each  one  of  these 
points  because  well-defined  tenderness  limited  to  such  point  usually  means 


Fig.   27.     Division   of  the   abdomen   into    regions   by   means    of   a   circle   with   a   two-inch    radius   and 

two-inch    horizontal    lines. 


an  affection  of  a  particular  organ.  It  must  be  kept  in  mind,  however,  that 
in  some  cases  such  point-tenderness  is  due  to  an  affection  of  some  adjacent 
organ  (as  when  inflammation  within  the  cecum  causes  tenderness  in  the 
appendix  region),  or  cA-en  of  some  distant  organ  which  has  become  displaced 
(as  Avhen  the  right  kidney  has  become  displaced  into  the  appendix  region). 

Again,  in  some  cases  tenderness  is  due  to  an  organic  or  functional  dis- 
turbance of  the  nerves  of  the  alxlominal  wall  or  to  reflected  pain,  due  to  a 


PHYSICAL,   EXAMIXATIOX 


53 


lesion  in  some  otlier  part  of  the  abcloniinal  cavity  or  to  some  organic  or 
functional  lesion  in  a  distant  part  of  the  body.  But  even  in  these  exceptional 
conditions  the  tenderness  is  usually  not  genuine  "point-tenderness,"  but 
is  more  extensive  and  can  be  traced  in  some  direction  sufficiently  far  to  in- 
dicate its  probable  origin. 


Fig.  28.  Another  abdomen  divided  with  the  circle  and  short  horizontal  lines,  and  showing  the 
names  on  the  primary  regions.  The  area  within  the  circle  carries  the  usual  designation,  "umbilical 
region." 


54 


GYNECOLOGIC   EXAMINATION    METHODS 


With  the  exceptions  above  mentioned  kept  in  mind,  the  special  areas  of 
''point-tenderness"  are  of  great  help  in  the  differential  diagnosis  of  ab- 
dominal lesions. 


K. 


t 


St 


'hO. 


Tr-O^ 


Fig.    29.      Various    areas    of    significant    Point-tenderness.      These    are    the    areas    to    be    investigated    during 
the    course    of    an    abdominal    examination. 


PHYSICAL   EXAMINATION 


55 


The  author  does  not  approve  of  the  method  of  naming  the  principal,  or 
primary,  regions  of  the  abdomen  from  the  significant  point-tenderness  situated 
therein.  For  example,  to  designate  the  right  lower  abdomen  as  the  "appen- 
diceal region, "  as  is  done  by  some  authorities,  leads  only  to  confusion.  It  is  no 
more  the  appendiceal  region  than  it  is  the  cecal  region,  or  the  tubo-ovarian 


Fig.  30.     Point  for  Kidney  Tenderness  laterally.  Fig.  31.     Points  for  Kidney  Tenderness  in  the  back. 


Fig.  32.  Relation  of  the  Kidney  to  the  lower 
margin  of  the  last  rib.  (Butler — Diagnostics  of 
Internal  Medicine.) 


Fig.    3Z. 


Trying   for   a   Fluid   Wave    across 
the  abdomen. 


region,  or  the  ureteral  region.  The  term  ''appendiceal  region"  should  be 
reserved  for  the  very  circumscribed  area  immediately  over  the  appendix, 
the  same  as  the  terms  "tubo-ovarian  region"  and  "ureteral  region"  should 


56  GYNECOLOGIC   EXAMINATION    METHODS 

be  limited  to  the  areas  containing  those  structures.  Then,  when  we  speak  of 
tenderness  in  the  appendiceal  region,  there  is  no  question  as  to  the  exact 
location  of  the  tenderness. 

The  principal  areas  of  significant  point-tenderness  are  shown  in  Fig.  29. 
There  are,  of  course,  also  many  areas  of  secondary  importance — of  secondary 
importance  because  tenderness  or  a  mass  therein  is  not  of  such  definite 
significance. 

After  locating  accurately  the  point  of  greatest  tenderness,  try  to  trace  the 
tenderness  in  various  directions.  This  is  especially  useful  in  cases  which  are 
doubtful,  because  the  tenderness  is  not  typically  situated  or  is  not  well  limited. 

For  example,  take  a  case  in  which  the  most  marked  point-tenderness  is 
situated  about  midway  between  the  right  tube,  the  appendix  and  the  ureter. 
It  may  be  due,  among  other  things,  to  disease  of  the  tube  or  ovary,  or  of  the 
ureter  or  cecum,  or  of  the  appendix  or  small  intestine,  or  of  the  peritoneum. 
Determine  if  well-marked  tenderness  can  be  traced  down  toward  Poupart's 
ligament  and  the  tube.  If  the  tenderness  does  not  extend  in  that  direction, 
it  is  probably  not  due  to  trouble  about  the  tube  or  ovary.  Then  try  to  trace 
it  to  the  ureter  and  along  the  ureter  downward  toward  the  bladder  and 
upward  toward  the  kidney.  Determine  also  if  it  spreads  over  the  cecum 
and  extends  up  along  the  ascending  colon,  as  it  is  likely  to  do  Avhen  caused 
by  inflammation  of  the  large  bowel.  Determine  if  it  extends  through  the  abdo- 
men generally,  including  the  umbilical  region  and  beyond. 

If  it  does  not  extend  in  any  one  of  the  directions  mentioned,  but  is  strictly 
limited  to  the  point  designated,  it  is  probably  due  to  appendix  trouble,  which 
probable  diagnosis  must  be  strengthened  or  weakened,  as  the  case  may  be,  by 
other  signs  present  and  by  the  history  of  the  trouble. 

In  those  cases  in  which  there  is  a  question  as  to  whether  or  not  the  tender- 
ness is  due  to  trouble  in  the  ureter,  particularly  where  the  tenderness  extends 
over  the  whole  right  lower  or  left  lower  abdomen,  or  is  so  acute  as  to  prevent 
the  deep  palpation  necessary  to  accurate  localization,  palpation  of  the  lumbar 
region  laterally  and  posteriorly  is  of  much  assistance  in  the  differential  diag- 
nosis. Well  marked  ureteritis  is  usually  accompanied  by  pyelitis  and  kidney 
tenderness.  In  such  a  case  there  is  distinct  tenderness  over  the  kidney  later- 
ally (Fig.  30)  and  also  posteriorly  (Figs.  31,  32). 

Mass  in  the  Abdomen 

When  a  mass  is  discovered,  determine  as  far  as  possible  its  position,  size, 
shape,  consistency,  tenderness,  mobility  and  attachments. 

The  position  of  a  mass  indicates  in  a  general  way  the  organ  or  group  of 
organs  from  which  it  arises.  Keep  in  mind,  hoAvever,  that  it  may  be  due  to 
some  adjacent  organ,  or  even  some  distant  organ  displaced  into  that  region. 

The  size  and  shape  of  a  mass  is  determined  by  ascertaining  its  length, 
breadth,  thickness,  and  general  contour.    The  length  or  height  of  a  tumor  pro- 


PHYSICAL   EXAMINATION 


57 


jecting  up  from  the  pelvis  is  usually  designated  as  so  many  inches  or  centi- 
meters above  the  pubic  symphysis,  or  beloAV  the  umbilicus  or  above  the 
umbilicus.  The  breadth  may  be  given  approximately  in  inches  or  centimeters, 
stating  at  the  same  time  Avhether  or  not  the  mass  is  situated  sj-mmetrieally 
on  either  side  of  the  median  line,  or  the  mass  may  be  referred  to  as  filling 
the  pelvis  from  side  to  side  or  as  filling  the  abdomen.  It  is  sometimes  difficult 
to  convey  a  satisfactory  idea  of  the  general  contour  of  a  mass  by  a  detailed 
description,  when  it  may  be  very  quickly  conveyed  by  referring  to  some  well- 
kno"\^Ti  object,  e.  g.,  an  egg,  a  lemon,  a  kidney,  or  an  hour-glass. 

Another  method  of  recording  the  size  and  shape  of  a  mass  is  to  draw  it 


i 


\ 


Fig.  34. — Differentiating  a  Fat  Wave  from  a  Fluid  \\'ave.     The  Fat  Wave  is  stopped  by  the  pressure 

in    the     median     line. 


within  a  stamped  outline  of  the  pelvis  and  abdomen.  Still  another  expedient, 
devised  by  H.  A.  Kelly  (Medical  Gynecology,  Chapter  i),  is  to  outline  the 
mass  and  the  landmarks  in  the  individual  patient  on  a  large  piece  of  gauze  or 
muslin  applied  over  the  abdomen,  the  same  being  preserved  as  part  of  the  case 
record. 

The  consistency  of  a  mass  should  be  carefully  determined.  Is  it  uniformly 
solid  or  does  it  present  hard  nodules,  or  does  it  contain  fluid?  If  the  mass  con- 
tains a  collection  of  fluid  of  sufficient  size,  there  may  be  elicited  that  peculiar 
sensation  known  as  fluctuation,  the  recognition  of  which  is  one  of  the  first 


58 


GYNECOLOGIC    EXAMINATION    METHODS 


lessons  in  surgical  work.  If  there  is  a  large  collection  of  fluid,  as  in  a  case  of 
marked  ascites,  a  fluid  wave,  started  by  tapping  on  one  side  of  the  abdomen, 
may  be  felt  by  the  other  hand  applied  to  the  other  side  (Fig.  33).  A  somewhat 
similar  wave  may  be  caused,  also,  by  a  thick  layer  of  subcutaneous  fat  (fat 
wave) .  In  such  a  case,  however,  if  an  assistant  press  lightly  in  the  median  line 
with  the  ulnar  edge  of  the  hand,  the  fat  wave  will  stop  at  the  line  of  pressure 
(Fig.  34). 

A  distinct  fluid  wave  maj^  be  obtained  in  any  large  collection  of  fluid  Avith 
a  comparatively  thin  wall.  It  is  present  in  well  marked  ascites,  in  unilocular 
cysts  and  in  multilocular  cysts  with  one  or  more  large  cavities.  Occasionally 
the  fact  that  there  are  different  large  cavities  in  the  cyst  may  be  surmised  by 
a  distinct  difference  in  the  fluid  wave  as  obtained  through  different  parts  of 
the  cyst.    In  a  cyst  .with  small  cavities  no  fluid  wave  is  obtained,  as  there  is 


Fig.   35.     Attempting  to   Displace  a   mass   upward   in   order  to   determine   if   it   has   a   pelvic   attachment. 


not  a  large  enough  single  cavity,  although  fluctuation  may  be  as  clear  as  in 
a  single  large  cyst.  Also,  in  a  cyst  with  thick  gelatinous  contents  a  fluid  Avave 
may  not  be  obtained. 

The  tenderness  of  a  mass  as  determined  by  palpation  is  of  much  importance 
in  differential  diagnosis.  In  acute  inflammation  (as  in  acute  salpingitis  or 
peritonitis),  or  in  acute  irritation  (as  in  hemorrhage  from  tubal  pregnancy), 
the  tenderness  is  very  marked.  On  the  other  hand,  in  uncomplicated  ovarian 
or  uterine  tumors,  tenderness  is  slight. 

The  mobility  and  attachments  of  a  mass  are  determined  by  attempting  to 
move  the  mass  in  different  directions.  The  fingers  are  worked  in  deeply  about 
the  mass  at  various  points,  and  it  is  determined  just  what  part  may  be  easily 
displaced  and  what  part  is  fixed  (Fig.  35).  The  fixed  point  of  a  mass  usually 
indicates  its  jDoint  of  origin — i.  e.,  the  organ  involved.    The  presence  or  absence 


PHYSICAL   EXAMINATION  59 

of  mobility  helps  to  determine  whether  or  not  the  mass  is  bound  down  by 
inflammatory  exudate  or  is  retroperitoneal,  or  is  in  the  abdominal  wall. 

Occasionally  a  mass  is  not  mobile  because  it  is  so  large  that  it  fills  the  ab- 
dominal cavity.  Some  retroperitoneal  masses  (particularly  kidney  tumors) 
present  marked  mobility  in  certain  directions. 

Fetal  Movement,  Uterine  Contraction,  Friction  Rub 

In  late  pregnancy,  fetal  movement,  caused  by  the  fetus  changing  position  or 
kicking,  may  not  infrequently  be  felt.  Dipping  the  hands  in  cold  water  and 
then  laying  them  flat  over  the  uterus  may  cause,  the  fetus  to  move. 

The  absence  of  fetal  movements  is  of  no  diagnostic  signiflcance,  but  the 
presence  of  them  is  of  course  certain  evidence  of  existing  iDregnancy  and  con- 
sequently well  worth  trying  for  in  a  doubtful  case. 

The  same  may  be  said  of  the  intermittent  contraction  and  relaxation  of  the 
pregnant  uterus.  In  some  cases  alternate  hardening  and  softening  of  the 
uterus  may  be  very  distinct,  and  is  positive  evidence  of  the  character  of  the 
mass  under  the  hands. 

A  friction  rub  may  sometimes  be  felt  in  a  case  of  active  peritonitis,  particu- 
larly in  the  local  plastic  or  irritative  peritonitis  that  not  infrequently  takes 
place  when  a  tumor  lies  against  the  abdominal  wall.  The  hand  is  pressed  over 
the  mass  during  forced  respiration.  Occasionally  the  friction  rub  may  be 
obtained  over  the  liver  or  spleen  when  there  is  a  local  peritonitis  there. 

PERCUSSION  OF  ABDOMEN 
Areas  of  Dullness 

Percussion  over  the  abdomen  serves  to  conflrm  the  information  obtained  by 
palpation,  and  also  brings  out  some  new  facts — for  example,  by  outlining 
accurately  the  area  of  dullness  it  shows  at  what  portion  of  the  abdominal  wall 
the  tumor  or  fluid  lies  against  the  wall,  and  at  what  portion  there  is  interven- 
ing intestine.  It  shows  also  whether  the  mass  or  fluid  changes  relations  when 
the  patient  changes  position.  In  a  ventral  hernia  (intestinal)  it  shows  that 
the  large  mass,  which  might  be  taken  for  a  tumor  or  inflammatory  mass,  is 
resonant — i.  e.,  it  contains  air,  and,  therefore,  must,  under  ordinary  circum- 
stances, contain  intestine. 

The  use  of  superficial  and  deep  percussion  in  succession  may  give  valuable 
information  in  some  cases.  Ordinary  percussion  (Fig.  36)  is  moderately  light 
and  superficial,  and  gives  resonance  over  all  the  normal  abdomen,  except 
where  the  liver  lies  against  the  wall.  In  marked  obesity,  however,  superficial 
percussion  is  likely  to  give  only  dullness  over  all  the  abdomen,  while  deep  per- 
cussion (a  hard  percussion  stroke  against  the  finger  pressed  in  deeply — Fig. 
37)  gives  resonance. 


60 


GYNECOLOGIC    EXAMINATION    Ml.THODS 


A  tumor  of  the  wall  or  of  the  omentum  ordinarily  gives  dullness  in  light 
percussion  and  resonance  in  deep  percussion. 


Fig.   36. 


Ordinary     Percussion,     which     is     usually 
rather    superficial. 


Fig.  37.  Deep  Percussion.  Notice  how  the  left 
index  finger  is  pressed  into  the  abdomen,  so  as  to 
thin   out  the  wall   and  get   closer  to   deep  structures. 


Endeavor  to  get  definitely  in  mind  exactly  the  reason  for  the  dullness  or 
resonance  found  in  a  particular  case,  and  then  its  diagnostic  significance  will 
be  clear. 

AUSCULTATION 

Fetal  Heart  Sounds,  Vascular  Murmur 

Auscultation,  either  by  the  ear  direct  (a  sheet  intervening)  or  by  the 
stethoscope,  should  always  be  employed  when  there  could  be  any  confusion 
with  advanced  pregnancy,  as  in  a  ease  of  large  ovarian  tumor  or  large  fibroid. 
The  fetal  heart  sounds  are  the  only  sounds  pathognomonic  of  pregnancy.  The 
placental  murmur  may  be  simulated  by  the  large  vessels  of  a  tumor.  The  ab- 
sence of  fetal  heart  sounds  does  not  exclude  pregnancy,  for  even  in  cases  of 
normal  pregnancy  they  cannot  always  be  heard.  Auscultation  should  be  em- 
ployed also  in  obscure  cases  of  pain  in  the  abdomen,  particularly  if  accom- 
panied by  pulsation.  The  pain  may  be  due  to  an  aneurism  of  the  abdominal 
aorta,  which  occasionally  runs  its  course  unrecognized  until  rupture  and  sud- 
den death.  In  auscultation  for  aneurismal  murmur  with  a  stethoscope,  be 
careful  that  the  abdominal  wall  is  not  pressed  firmly  against  the  aorta  with 
the  stethoscope,  for  such  pressure  will  cause  a  murmur  in  a  normal  vessel. 

Excessive  gurg-ling"  in  the  intestines  may  be  heard  in  most  intestinal  diseases 


i 


^"HYSICAL   EXAMINATION 


61 


accompanied  with  tympanites.  It  is  heard  particularly  in  the  region  of  the 
ileocecal  valve  or  about  a  partial  obstruction  or  over  a  loop  of  bowel  in  peri- 
staltic movement.  Gurgling  over  a  large  mass  indicates  that  one  or  more  intes- 
tinal coils  are  between  it  and  the  abdominal  wall.  This  intestine  may  be  in 
front  because  the  mass  is  retroperitoneal  or  because  an  intestinal  coil  is 
adherent  over  the  mass,  or  because  the  mass  is  made  up  partly  or  wholly  of 
adherent  intestinal  coils. 


11^ 


Fig.    38.      Showing   the   lines   for   Mensuration. 


A  friction  sound  may  occasionally  be  heard  in  local  peritonitis,  particularly 
over  the  areas  of  fresh  plastic  peritonitis  or  over  a  tumor. 


MENSURATION  OF  ABDOMEN 

Measure  the  abdomen  when  it  is  very  large  or  when  there  is  a  growing 
tumor,  or  when  for  other  reason  it  may  be  desirable  to  know  exactly  any  differ- 
ence in  size  some  weeks  or  months  hence,  or  when  it  is  desired  to  speak  with 
accuracy  concerning  the  size  of  the  abdomen  in  the  case  of  a  large  growth. 

The  measurements  are  made  with  the  ordinary  tape-line.    AVhen  measuring 


62  GYNECOLOGIC   EXAMINATION    METHODS 

a  patient,  take  enough  measurements  to  make  an  accurate  record.  Measure- 
ments along  the  lines  shown  in  Fig.  38  will  show  variations  with  a  large  growth 
in  any  part  of  the  peritoneal  cavity.    They  are  as  follows: 

1.  From  umbilicus  to  sternal  notch. 

2.  From  umbilicus  to  pubes. 

3.  From  umbilicus  to  right  anterior  superior  iliac  spine. 

4.  From  umbilicus  to  left  anterior  superior  iliac  spine. 

5.  Circumference  of  body  at  level  of  umbilicus. 

6.  Circumference  of  body  3  inches  above  umbilicus. 

7.  Circumference  of  body  3  inches  below  umbilicus. 

EXAMINATION  OF  EXTERNAL  GENITALS  AND  ADJACENT 

STRUCTURES 

If  the  patient  complains  of  irritation  about  the  external  genitals,  or  of  itch- 
ing or  burning,  or  of  frequent  or  painful  urination,  or  of  sores  or  swelling,  or 
discharge,  the  parts  should  be  inspected  in  a  good  light.  For  this  examination, 
as  the  patient  is  lying  on  the  table,  the  lower  extremities  are  covered  with  a 
sheet,  the  skirts  are  pushed  above  the  knees  and  out  of  the  way,  and  the  hips 
are  brought  to  the  end  of  the  table,  as  shown  in  Fig.  39. 

A  general  inspection  is  then  given  the  parts,  to  ascertain  if  they  are  prac- 
tically normal  (Figs.  40,  41)  or  if  there  is  marked  abnormality.  The  labia  are 
then  separated,  to  expose  the  vestibule  and  urethral  and  vaginal  openings, 
and  also  the  openings  of  the  ducts  of- the  vulvo-vaginal  glands. 

By  examination  determine  if  any  of  the  following  conditions  are  present: 
Discharge — Muco-epithelial,  Muco-purulent,  Purulent,  Bloody,  Watery. 
Inflammation — Gonorrheal  or  otherwise. 

Ulcer— Simple,  Chancroidal,  Syphilitic,  Tubercular,  Malignant. 
SweUing- — Inflammatory,     Stasis     Infiltration,     Edema,     Hematoma, 

Hernia,  Cyst. 
New  Growth — Condyloma,  Urethral  Caruncle,  Lipoma,  Fibroma,  Ma- 
lignant Growth. 
Malformation — Adhesions  of  Labia,  Pseudohermaphroditism. 

Determine  also  the 

Condition  of  Hymen — Intact,  Lacerated,  Destroyed. 
Condition  of  Perineum — Normal,  Lacerated   (wide  opening,  vaginal 
walls  visible,  shallow  perineum,  scar  tissue,  fistula). 

DISCHARGE   ABOUT   EXTERNAL    GENITALS 

Muco-epithelial,  Muco-purulent,  Purulent,  Bloody,  Watery 

Muco-epithelial  Discharge  (normal).  The  normal  mucus  secretion  from 
the  cervix  moistens  and  macerates  the  vaginal  epithelium.  The  mixture  of  this 
cervical  mucus  and  vaginal  epithelium  appears  at  the  external  genitals  as  a 


EXAMINATION    OF   EXTERNAL    GENITALS 


63 


white,  crumbly  discharge.  Usually  it  is  hardly  noticeable,  only  just  enough 
to  keep  the  parts  normally  moist.  At  the  menstrual  periods,  and  under  other 
conditions  favoring  pelvic  congestion,  it  may  increase  so  as  to  be  somewhat 
annoying  to  the  patient,  though  hardly  of  pathologic  importance. 

Muco-purulent  Discharg-e.     When  there  is  inflammation  or  persistent  con- 
gestion in  the  uterus,  the  mucus  secretion  is  much  increased,  and  there  are 


Fig.    39.      Patient    in    position    for    Examination    of    External    Genitals    and    adjacent    structures. 


thrown  out,  at  the  same  time  and  for  the  same  cause,  many  leukocytes,  Avhich 
mix  with  the  mucus,  giving  it  somewhat  of  a  purulent  character,  the  promi- 
nence of  the  purulent  feature  depending  on  the  amount  of  this  admixture  of 
dead  leukocytes.  If  it  contains  enough  mucus  to  be  noticeable,  the  discharge 
is  sticky  and  stringy,  and  may  be  drawn  out  into  long  threads. 

Purulent  discharge  presents  the  appearance  of  pus,  as  from  an  abscess  or 
inflamed  surface,  either  thin  pus  or  thick  yellow  pus.     Determine  just  where 


64 


GYXECOLOGIC    EXAMIXATIOX    :METH0DS 


Fig.  40.  External  Genitals,  i.  Mons  veneris.  3.  Left  Labium  Majus,  drawn  aside.  3.  Clitoris. 
4.  Left  Labium  Minus,  slightly  larger  than  the  average.  5.  Vestibule.  6.  Urethra.  7.  Duct  of  Vulvo- 
vaginal   Gland.      8.    Vaginal    Entrance.  9.    Remains    of    Hymen.      10.    Fourchette.      //.    Anus.       (Byford — 

Manual    of    Gynecology.) 


Fig.  41. 


Practically    Xormal    External    Genitals — multipara,   labia   together, 
labia    minora    can    hardly    be    called    abnormal. 


The   corrugations   of   the 


EXAMINATION    OF   EXTERNAL    GENITALS  65 

this  comes  from — i.  c,  whethev  i'l'oiu  the  uvethi-a  or  vulvo-vagiiial  gland,  or 
inflamed  surfaces  on  the  external  genitals  or  from  the  vagina. 

Dip  the  tip  of  a  cotton-wrapped  applicator  in  this  pnrnleiit  discharge  and 
spread  some  on  a  microscopic  slide. 

If  possible,  secure  some  discharge  from  the  urethra  or  vulvo-vaginal  gland, 
for  the  pus  from  these  situations  is  much  more  satisfactory  for  microscopic 
examination  than  the  mixed  vulvar  or  vaginal  discharge. 

To  secure  urethral  pus,  separate  the  labia,  cleanse  the  meatus,  and  compress 
the  internal  end  of  the  urethra  by  pressure  against  the  anterior  vaginal  wall 
with  the  tip  of  the  index  finger.  Then,  still  maintaining  the  pressure,  draw 
the  tip  of  the  finger  along  the  urethra  toward  the  meatus  (Fig.  42).  This 
brings  the  urethral  pus  to  the  meatus  (Fig.  43). 

Chronic  inflammation  in  the  urethra  is  likely  to  be  situated  in  Skene's 
glands,  and  in  such  a  case  some  pus  may  be  pressed  from  these  small  glands 
by  compressing  the  urethra  (by  pressure  through  anterior  vaginal  Avail)  just 
back  of  the  meatus.  In  some  cases,  particularly  in  a  multipara,  the  urethral 
mucosa  pouts  out,  so  that  by  careful  examination  the  orifice  of  one  or  both 
of  Skene's  glands  may  be  seen.  Fig.  44  shows  such  a  gland-opening  (left 
side)  and  also  a  drop  of  pus  which  has  been  pressed  from  the  gland  on  the 
right  side. 

The  vulvo-vaginal  glands  (Bartholin's  glands)  are  situated  symmetrically 
on  either  side  of  the  vaginal  opening,  as  shoAvn  in  Fig.  45.  The  opening  of 
the  duct  of  the  gland  of  each  side  is  situated  laterally,  just  in  front  of  the 
remnants  of  the  hymen  and  a  little  beloAV  the  middle  of  the  lateral  margin  of 
the  vaginal  opening.  Draw  aside  the  labia  in  this  situation  and  look  for  the 
opening  of  the  gland,  and  determine  Avhether  or  not  the  opening  is  reddened 
and  if  there  is  any  discharge  from  it  (Fig.  46). 

To  examine  either  vulvo-vaginal  gland,  to  determine  if  there  is  anj^  thick- 
ening or  tenderness  from  infl.ammation,  or  if  pus  can  be  squeezed  from  it,  grasp 
the  region  of  the  gland  between  the  index  finger  in  the  vagina  and  the  thumb 
outside,  as  shown  in  Fig.  47. 

When  securing  secretion  for  microscopic  examination,  it  is  well  to  take 
discharge  from  different  localities,  making  the  spread  Avith  the  applicator-tip 
in  the  form  of  different  letters  for  different  regions — for  example,  U  (urethra), 
V  (vagina),  C  (cervix).  If  the  specimens  are  to  be  sent  to  a  laboratory,  stick 
a  small  label  to  each  slide,  and  Avrite  on  it  the  date,  the  patient's  initials,  and 
the  exact  locality  from  Avhich  it  Avas  taken.  In  a  doubtful  case  of  urethritis, 
in  Avhich  no  secretion  can  be  secured  at  the  first  examination,  direct  the  patient 
to  pass  no  urine  for  tAvo  or  three  hours  before  the  next  examination.  Detailed 
directions  for  staining  the  gonoeoecus  Avill  be  found  under  Gonorrhea  in  Chap- 
ter IV. 

Bloody  Discharg-e.  The  discharge  is  red  or  brown,  the  intensity  of  the 
color  depending,  of  course,  upon  the  amount  of  blood.     It  varies  all  the  Avay 


66  GYNECOLOGIC    EXAMINATION    METHODS 

from  a  slight  reddish  or  broAvnish  tinge,  hardly  noticeable,  to  practically  pure 
blood  or  clots.  The  blood  may  be  mixed  with  any  of  the  other  pathologic 
discharges— muco-puruleut,  purulent  or  watery.  The  causes  of  blood  in  the 
vaginal  discharge  are  enumerated  in  Chapter  ii. 

Watery  Discharge.  A  portion  of  the  discharge  appears  like  Avater.  This 
may  be  associated  with  the  normal  muco-epithelial  discharge  or  with  a  muco- 
purulent or  purulent  discharge.  The  most  common  cause  of  a  watery  dis- 
charge is  the  decomposition  of  a  malignant  tumor-mass  in  the  vagina  or 
uterus,  giving  the  characteristic  watery,  foul-smelling  discharge  of  advanced 
cancer  or  sloughing  fibroid. 

INFLAMMATION  ABOUT   EXTERNAL   GENITALS 

Gonorrheal  or  Otherwise 

Inflammation  is  indicated  by  redness  and  tenderness,  either  diffused  or  in 
spots.  It  is  usually  accompanied  by  smarting  or  burning  on  urination.  The 
smarting  on  urination  and  the  increased  frequency  of  urination  are  most 
marked  Avhen  the  urethra  is  involved. 

ULCER  ABOUT  EXTERNAL  GENITALS 

Simple,  Chancroidal,  Syphilitic,  Tubercular,  Malignant 

If  an  ulcer  is  found,  determine  its  position,  size,  shape,  consistency  (edge 
and  underlying  tissues),  tenderness  and  mobility  (Avhether  fixed  to  under- 
lying deep  structures  or  freely  movable).  Determine  also  the  character  of  the 
discharge  from  it,  and  whether  it  bleeds  readily  on  touching.  Notice  whether 
the  base  is  made  of  regular  granulation  tissue  or  has  yellow  dots  scattered 
in  it,  or  is  filled  with  a  slough.  Examine  also  the  edges — do  they  slope  from 
within  outward,  as  in  an  ordinary  ulcer  when  healing,  or  are  they  sharp-cul 
and  perpendicular,  or  undermined  as  in  a  rapidly  spreading  chancroid?  Is 
there  a  red  acute-inflammatory  zone  about  the  ulcer  or  is  there  a  wide  area 
of  chronic  infiltration  (chronic  inflammation,  malignant)  ?  Is  there  only  a 
single  sore  or  are  there  several?  Are  the  inguinal  glands  affected?  If  so,  in 
what  way?  Is  there  any  other  condition  indicating  the  cause  and  character 
of  the  ulcer  ?  For  the  differential  diagnosis  of  the  various  kinds  of  ulcer  see 
the  consideration  of  ulcers  in  Chapters  ii  and  Iv. 

SWELLING  ABOUT  EXTERNAL   GENITALS 
Inflammation,   Stasis  Infiltration,   Edema,   Hematoma,  Hernia,   Cyst 

Swelling  may  l)e  inflammatory  (as  in  acute  edema  or  abscess),  or  ob- 
structive (as  in  edema  from  ol)structi()ii  l)y  heart  or  liver  disease  or  from 
tumoi'  in  abdomen  oi-  pelvis).     Thei'e  may  be  obsti'uctive  edema  and  infiltra- 


EXAMINATION    OP    EXTERNAL    GENITALS 


67 


Fig.    42.      Method    of    pressing    pus    from    the    depth      Fig.  43. 
of  the   urethra   to   the   meatus. 


Aiiijearaiice  of  pus  at  the  urethral  opening. 


Fig.  44.  Slight  eversion  of  urethral  mucosa,  so 
that  openings  of  Skene's  glands  come  into  view. 
Tin  left  side  the  gland  opening  is  seen.  On  right 
side  a  drop  of  pus  has  been  squeezed  from  the 
gland  and  partially  obscures  the  field.  (Kelly — 
Operative    Gynecology.') 


Fig.  45.  \'ulvo-vaginal  gland  (D)  and  duct  (O 
of  right  side.  ( Dyford,  after  Muguier — Manual  of 
Gynecology.) 


68 


GYNECOLOGIC    EXAMIXATIOX    METHODS 


tioii  from  scar-tissue  about  tlie  pubic  arch  (stasis  hypertrophy  J,  or  edema  and 
infiltration  from  obstruction  of  vessels  by  til  aria  (elephantiasis). 

The  swelling  may  be  a  pudendal  hernia,  which  originates  either  as  an 
inguinal  or  a  vaginal  hernia. 

The  swelling  may  be  a  retention  cyst,  the  most  common  of  which  is  cyst 
of  the  vulvo-vaginal  gland.  For  complete  enumeration  and  differential  diag'- 
nosis  of  vulvar  swellings  see  Chapter  ii  and  Chapter  iv. 


Fig.    46.     Appearance    of   pus   about    the    opening    of  Fig-   ■+/.     Palpating   the    left   vulvo-vaginal   gland, 

the    left    vulvo-vaginal    gland.  to  determine  if  there  is  thickening  or  tenderness,  or 

if  pus  can  be  pressed  from  it. 


NEW  GROWTHS  ABOUT  EXTERNAL  GfENITALS 
Condyloma,  Urethral  Caruncle,  Lipoma,  Fibroma,  Malignant  Growths 

Condylomata  are  small  papillomata,  from  pin-head  to  hazel-nut  size,  that 
appear  about  the  labia  and  meatus  as  the  result  of  chronic  irritation.  They 
are  seen  most  frequently  in  gonorrhea  and  secondary  syphilis.  Occasionally 
condylomatous  growths  unite  to  form  a  large  mass,  as  shown  in  Chapter  ii. 

Caruncle  is  a  papilloma  occurring  about  the  meatus.  Usually  it  is  ex- 
tremely tender. 


DIGITAL    VAGINAL    EXAMINATION  69 

Fibroma,  lipoma  and  other  non-nialignant  tumors  are  rare,  although  they 
do  occur  occasionally,  fibroma  being  the  most  frequent. 

Malig-nant  growths  in  this  situation  very  rapidly  reach  the  stage  at  which 
complete  extirpation  is  impossible,  hence  the  importance  of  recognizing  the 
condition  very  early. 

CONDITION  OF  HYMEN 

Intact,  Lacerated,  Destroyed 

Does  the  hymen  present  the  virginal  appearance,  or  is  it  lax  and  the  open- 
ing large,  as  from  sexual  intercourse,  or  is  it  destroyed  from  labor,  being 
represented  by  only  a  few  remnants  (carunculae  myrtiformes)  ? 

CONDITION  OF  PERINEUM 
Wide  Opening,  Vaginal  Walls  Visible,  Shallow  Perineum,  Scar-tissue,  Fistula 

For  the  detailed  diagnosis  of  lacerations  see  Chapter  ii. 

VAGINAL  EXAMINATION  (DIGITAL) 

In  the  vaginal  examination,  or  digital  examination,  as  it  is  frequently 
designated,  one  or  two  fingers  are  introduced  into  the  vagina  and  the  struc- 
tures within  reach  are  palpated.  In  this  way  valuable  information  may  be 
obtained  in  certain  cases.  It  is  also  a  preliminary  step  to  the  important 
vagino-abdominal  or  bimanual  examination,  to  be  taken  up  later. 

Method  of  Examination 

Use  two  fingers  for  the  vaginal  palpation  where  the  size  of  the  vaginal 
opening  will  permit.  A  much  deeper  and  more  accurate  examination  can  be 
made  with  both  the  index  and  middle  finger,  than  Avith  the  index  finger 
alone.  Ordinarily  in  the  examination  of  a  married  woman,  even  one  Avho  has 
had  no  children,  two  fingers  may  be  introduced  Avithout  difficulty,  provided  the 
fingers  are  Avell  lubricated  and  care  is  taken  to  cause  no  pain. 

It  is  important  also  to  separate  the  labia  Avith  the  fingers  of  the  other  hand 
Avhile  the  examining  fingers  are  being  introduced,  for,  if  the  hair  and  labia 
are  alloAved  to  roll  in  Avith  the  examining  fingers,  much  pain  is  caused  the 
patient  and  the  opening  is  considerably  narroAved. 

It  is  achasable  to  use  rubber  gloves  in  practically  all  cases.  When  intact, 
they  give  complete  protection  against  syphilis  or  other  infection  Avhich  might 
come  through  an  unnoticed  abrasion  about  the  fingers.  Another  advantage  is 
that  less  scrubbing  of  the  hands  is  needed  after  the  examination.  Frequent 
severe  scrubbing  of  the  hands  and  the  use  of  strong  antiseptic  solutions  keep 
the  skin  in  an  irritated,  unhealthy  condition,  particularly  in  cokl  Aveather. 


70 


GYNECOLOGIC    EXAMINATION    METHODS 


Fig.   48.     Position   of   the   fingers   for   the   vaginal   and   vagino-abdominal   examinations. 


Fig.   49.     Same   hand,   gloved   and    ready   for   the   examination. 


DIGITAL    VAGINAL    EXAMINATION 


71 


When  rubber  gloves  are  used,  all  the  infectious  material  is  removed  with  the 
gloves,  Avhich  are  washed  and  boiled  and  are  then  ready  for  the  next  exam- 
ination. 

Fig.  48  shows  the  position  of  the  fingers  ordinaril.v  preferable  in  the  vaginal 
and  bimanual  examination.  Fig.  49  shows  the  hand  gloved  and  ready  for 
the  vaginal  examination.  Fig.  50  shoAvs  the  disposition  of  the  outside  fingers 
and  the  thumb  as  the  examination  is.  being  made.  The  third  and  fourth 
fingers  are  folded  into  the  palm  ,of  the  hand  as  far  as  possible,  and  care  is 
taken  to  maintain  extension  of  the  thumb,  so  that  it  does  not  infringe  upon 
the  genitals  in  the  region  of  tho  clitoris.     For  the  same  reason,  in  the  deep 


Kig.     SO.       The    gloved     hand     making    the    vaginal     examination.       The     thumb     is     held     awaj'     from     the 
genitals,    and    the    third    and    fourth    fingers    are    folded    into    the    palm. 


internal  palpation  the  wrist  should  be  dropped  low  and  the  examining  fingers 
directed  upward,  so  as  to  throw  the  thumb  away  from  the  genitals.  In  the 
yery  deep  palpation  in  the  sides  of  the  pelvis,  when  the  thumb  is  necessarily 
in  the  way,  it  should  be  turned  far  to  one  side  or  the  other,  and  thus  kept 
from  contact  with  the  sensitive  areas  (Fig.  76).  In  regard  to  the  disposition 
of  the  third  and  fourth  fingers,  it  is  advantageous  in  some  cases,  particularly 
in  very  stout  patients,  to  extend  these  fingers  along  in  the  internatal  fold, 
as  shown  in  Fig.  60.  In  these  exceptional  cases  this  permits  deeper  penetra- 
tion of  the  examining  fingers. 

In  beginning  the  examination,   as  the  examining  fingers  are  being  intro- 


72  GYNECOLOGIC   EXAMINATION    METHODS 

duced,  there  is  frequently  a  tendency  on  the  part  of  the  patient,  who  is 
nervous  for  fear  of  pain  or  uncertain  as  to  whether  there  will  be  pain,  to 
contract  the  muscles  of  the  pelvic  floor  and  thus  interfere  with  the  vaginal 
examination.  In  such  a  case,  if  one  finger  be  introduced  a  short  distance  and 
steady  pressure  backward  be  made  against  the  muscle  (Fig.  89),  it  slowly 
relaxes  and  the  second  finger  may  be  introduced  beside  the  first.  Remember, 
that  to  obtain  more  space  at  the  vaginal  orifice,  either  in  digital  examination 
or  in  introducing  a  speculum,  always  press  downward  against  the  pelvic 
sling.  Above  and  to  the  sides  of  the  opening  is  the  bony  arch  (Fig.  51),.  and 
if  an  attempt  is  made  to  overcome  the  resistance  by  direct  forward  pressure, 
without  depressing  the  perineum,  the  soft  tissues  above  are  pinched  between 
the  finger  or  instrument  and  the  bony  arch,  causing  the  patient  pain  and  in- 
creasing the  muscular  resistance. 

In  a  woman  Avho  has  borne  children  the  opening  usually  admits  the  U\o 
fingers  somewhat  easier,  and  the  temporary  muscular  resistance  above  men- 
tioned is  seldom  encountered. 

What  Structures  to  Palpate 

With  one  or  tAvo  fingers,  well  lubricated  and  introduced  into  the  vagina,- 
palpate  the  following  structures: 

Vaginal  Walls — Roughness,  Tenderness,  Discharge,  Induration,  Swell- 
ing, Stricture. 
Base  of  Bladder — Tenderness,  Induration. 
Urethra — Tenderness,  Induration,  Discharge. 
Vulvo-vaginal  Glands — Tenderness,  Induration,  Discharge,  Red  Spot. 

Size  of  opening. 

Resistance  to  backward  pressure, 
Pelvic  Floor    \    Protrusion  of  vaginal  walls, 
Scars  and  distortions. 
Thickness  of  perineum. 

Rectum — Tenderness,  Induration,  Hemorrhoids,  Fistula,  Fissure. 

Position, 

Size  and  shape. 

Consistency, 

Tenderness, 

Mobility, 

Direction  of  canal. 

Laceration  and  eversion  of  lips. 

Size  and  shape  of  external  os. 

Pericervical  Tissues— Tenderness,   Induration. 


Cervix  Uteri 


DIGITAL    VAGINAL    EXAMINATION  •  73 

VAGINAL  WALLS 
Roughness,  Tenderness,  Induration,  Swelling,  Stricture 

111  acute  vaginitis  and  in  some  cases  of  chronic  vaginitis  the  surfaces  Avithin 
the  vagina  have  a  rough,  granular  feel  and  are  tender  on  pressure.  An 
astringent  douche — for  example,  a  bichloride  douche,  or  one  containing  zinc 
sulphate  or  tannic  acid  or  alum — will  cause  a  similar  roughness.  But  if  the 
vagina  is  both  rough  and  tender,  it  is  almost  certainly  inflamed,  providing 
the  tenderness  is  not  due  to  some  perivaginal  trouble.  Of  course,  the  diag- 
nosis of  vaginitis  does  not  depend  on  this  alone,  but  is  aided  by  facts  deter- 
mined in  the  speculum  examination,  and  also  by  the  history  of  the  case. 

"When  discharge  is  felt  in  the  vagina,  the  assumption  is  that  it  comes  from 
the  uterus  unless  there  are  indications  of  inflammation  in  the  vagina.  If  the 
vagina  is  roughened  and  tender,  the  discharge  probably  originates  there. 
Whether  or  not  it  really  does  originate  there,  is  determined  in  the  speculum 
examination. 

Induration,  or  a  hard  place  felt  at  some  part  of  the  vaginal  wall,  may  b? 
due  to  infiltration  of  the  wall  itself  (inflammation,  scar-tissue,  small  cyst,  ma- 
lignant disease)  or  to  some  trouble  back  of  the  wall. 

A  swelling  or  mass  in  the  vaginal  wall  or  bulging  into  the  vagina  frciii  any 
direction  may  be  due  to  any  one  of  a  number  of  conditions  which  are  men- 
tioned in  detail  in  Chapter  ii. 

A  stricture  (narrowing)  or  atresia  (occlusion)  of  the  vaginal  canal  may  be 
a  congenital  malformation  or  may  be  an  acquired  condition  resulting  from 
injuries,  in  labor  or  othei'Avise,  or  from  severe  or  protracted  inflammation,  as 
in  the  adhesive  or  obliterative  vaginitis  seen  frequently  in  aged  patients. 
The  narrowing  of  the  canal  may  be  due  also  to  pressure  of  a  tumor  or  an  in- 
flammatory mass  around  the  vagina. 

BASE  OF  BLADDER 
Tenderness,  Induration 

The  base  of  the  bladder  lies  directly  beneath  the  central  part  of  the  an- 
terior vaginal  wall  and  is  readily  palpated.  In  cystitis  or  other  painful  affec- 
tion involving  the  base  of  the  bladder,  tenderness  is  found.  When  induration 
or  abnormal  hardening  or  thickening  is  found,  ascertain  whether  it  is  a  dis- 
tinct mass  Avith  definite  outlines  (foreign  body  or  tumor  of  the  bladder),  or  a 
diffuse  infiltration  (infiammatory,  tubercular,  malignant)  of  the  bladder  Avail 
or  of  the  vesico-A^aginal  septum. 


74 


GYNECOLOGIC   EXAMINATION    METHODS 


URETHRA 

Tenderness,  Induration,  Discharge 

The  urethra,  as  it  extends  from  the  bladder  forward  under  the  pubic  arch, 
is  easily  palpated  through  the  anterior  vaginal  wall,  immediately  beneath 
which  it  lies.  In  inflammation  of  the  urethra  there  is  usually  considerable 
tenderness,  and,  in  many  cases,  decided  induration  or  thickening.  A  thicken- 
ing due  to  a  new  growth  may  be  easily  outlined  in  this  way.     Palpate  the 


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Fig.   51.     The   bony  ai'ch,   which  bounds  the  vaginal   oiiening  aliove. 


uretJira  from  within  out-ward — i.  e.,  from  the  bladder  toward  the  meatus. 
The  palpation  is  more  accurately  and  conveniently  accomplished  in  that  way. 
and  at  the  same  time  any  discharge  in  the  urethra  is  carried  to  the  meatus, 
where  it  is  seen  and  a  specimen  secured  for  microscopic  examination. 

Remember  that  inflammation  may  persist  indefinitely  in  Skene's  glands, 
just  within  the  meatus.    To  secure  secretion  from  the  glands  for  examination 


DIGITAL   VAGINAL   EXAMINATION  75 

ill  such  eases,  introduce  the  index-finger  within  the  vagina  and  compress  the 
urethra  just  back  of  the  meatus,  and  then  move  the  finger  forward.  In  parous 
women  the  opening  of  each  gland  may  often  be  found  by  rolling  out  the 
urethral  mucosa  slightly  and  examining  closely  for  the  opening  (Fig.  44). 

VULYO-VAGIXAL  GLAND 
Tenderness,  Induration,  Discharge,  Eed  Spot 

The  vulvo-vaginal  gland  (gland  of  Bartholin)  of  each  side  lies  just  lateral 
to  the  remnants  of  the  hymen,  and  opens  by  a  short  duct  in  front  of  and 
a  little  beloAv  the  middle  of  the  lateral  margin  of  the  hymenal  attachment. 
A  convenient  way  to  palpate  the  glands  is  to  catch  the  tissues  lateral  to  the 
gland  opening  (the  opening  may  be  easily  seen  in  the  situation  just  described) 
between  a  finger  in  the  vagina  and  the  thumb  outside  (Fig.  47). 

When  normal  the  gland  is  scarcely  noticeable  by  ordinary  palpation. 
When  inflamed,  however,  there  is  thickening,  and  the  gland  is  felt  as  a  small 
firm  nodule. 

There  is  tenderness  also,  and,  if  the  gland  is  pressed  upon,  some  discharge 
(pus)  may  appear  from  duct.  ]\Iake  a  smear  preparation  of  this  for  staining 
for  gonococci. 

In  a  case  of  al^scess  or  cyst  the  nodule  will  be  much  larger.  A  well- 
marked  red  spot  or  small  red  area  involving  the  opening  of  the  gland  duct 
indicates  previous  inflammation  of  the  duct,  and  is  presumptive  evidence  of  a 
previous  gonorrhoeal  infection  (as  other  forms  of  inflammation  seldom  involve 
the  gland  or  duct),  and  should  always  lead  to  further  investigation,  to  estab- 
lish the  presence  or  absence  of  this  disease. 

PELVIC  FLOOR 

Size  of  Vaginal  Opening,  Resistance  to  Backward  Pressure  on  Pelvic  Floor, 
Protrusion  of  Vaginal  V/alls,  Scars  or  Distortions, 
Thickness  of  Perineal  Body- 
Is  there  loss  of  support  at  the  pelvic  outlet!    Is  there  so  much  relaxation, 
due  to  imperfect  healing  of  an  open  tear  or  of  a  subcutaneous  tear,  or  due  to 
subinvolution  of  the  pelvic  sling,  that  the  pelvic  organs  are  not  satisfactorily 
supported?     To  determine  this,  investigate  the  following  points: 

Size  of  Vaginal  Opening.  In  the  adult  virgin  the  opening  in  the  hymen 
will  usually  admit  the  little  finger  without  much  stretching.  In  a  married 
woman  two  fingers  can  usually  be  introduced  for  examination  without  caus- 
ing pain,  provided  the  care  previously  mentioned  is  exercised. 

If  the  vaginal  opening  will  readily  admit  three  fingers,  it  is  decidedly  en- 
larged and  there  is  considerable  interference  with  the  integrity  of  the  perineal 
body.     The  perineal  body  is  not,  however,  an  important  factor  in  the  real 


76 


GYNECOLOGIC    EXAMIXATIOX    METHODS 


supporting  power  of  the  pelvic  floor ;  hence  a  relaxed  vaginal  opening  does 
not  necessarily  mean  a  relaxed  pelvic  sling,  though  it  usually  accompanies 
the  same. 

Resistance  to  Downward  and  Backward  Pressure  on  the  Pelvic  Floor. 
Usually  in  the  woman  who  has  borne  children  there  is  not  the  firm  support 
back  of  the  posterior  vaginal  wall,  and  extending  well  up  toward  the  cervix, 
that  is  found  in  nullipara.  There  is  not,  however,  the  marked  difference  one 
"svould  naturally  expect  from  the  enormous  stretching  that  necessarily  takes 
place  in  childbirth. 

The  provisions  of  Nature  for  the  restoration  of  the  parts  to  near  their 


Fig. 


Testing    the    left    sulcus. 


former  condition  ai-e  wonderfully  effective  when  not  interfered  with  by  tears 
or  over-stretching  or  su])iin'olution. 

The  resistance  in  each  sulcus  may  be  tested  Avith  one  finger,  as  shown  in 
Fig.  52,  to  determine  if  there  has  been  a  tear  in  the  levator  ani  in  that  region, 
with  consequent  relaxation. 

A  much  more  satisfactory  method  of  testing  the  integrity  of  the  pelvic 
floor  is  to  introduce  the  two  examining  fingers  and  turn  tliem  so  that  their 
palmar  surfaces  are  directed  backward.  Then  press  backAvard  and  dowmvard 
on  the  pelvic  floor,  at  the  same  time  separating  Hie  fingers  as  widely  as  pos- 
sible (Fig.  53). 


DIGITAL   VAGIXAL    EXA^nXATIOX 


77 


The  fingei-s  in  tlie  ^'agilla  are  separated  as  sh()\\ii  in  Fio-.  54.  This  iiia- 
iieuver  AviU  give  a  very  good  idea  of  the  amount  of  support  furnished  ])y  the 
pelvic  sling  and  of  the  downward  displacement  of  the  pelvic  organs  that  is  per- 
mitted when  the  patient  is  standing.  Another  useful  method  is  to  introduce 
the  two  index  fingers,  side  hy  side,  into  the  vagina  and  then  separate  them 
^videly  in  a  direction  dowuAvard  and  outward  (Fig.  55 j.  If  the  fingers  can  he 
carried  to  the  bony  sides  of  the  arch  with  but  little  muscular  resistance,  the 
front  part  of  the  levator  ani  muscle  and  accompanying  fascia  has  been  torn, 
and  thei'e  is  decided  loss  of  support  in  the  pelvic  floor.  If  now  the  patient 
be  directed  to  bear  down,  the  loss  of  support  becomes  still  more  evident. 

Occasionally,  even  in  case  of  marked  injury  to  the  pelvic  sling,  the  support 
Avill  seem  yevy  good  during  the  fii-st  part  of  the  examination  because  of  the 
muscular  tension. 


Fig.  33.  Testing  the  pelvic  floor.  The  vaginal 
fingers  are  separated  widely,  as  explained  in  Fig.  54, 
and   pressed   downward. 


Fig.  54.  Showing  the  relative  position  of  the 
fingers  when  in  the  vagina,  while  testing  the  pelvic 
floor. 


The  strong  fascial  layer  of  the  pelvic  sling  probably  constitutes  the  prin- 
cipal factor  in  continuous  support,  for  the  muscles  cannot  contract  continuously. 

Now,  the  fascia  may  be  so  torn  and. stretched  that  it  furnishes  little  or  no 
continuous  support,  and  yet,  as  long  as  the  muscles  stay  contracted,  there 
seems  to  be  a  fairly  good  pelvic  floor.  Any  error  in  this  respect  may  be 
avoided  by  watching  for  it,  and  securing  entire  relaxation  before  the  exami- 
nation is  finished. 

Protrusion  of  Anterior  or  Posterior  Wall.  To  further  test  the  loss  of  sup- 
port, separate  the  labia  and  insti-uct  the  patient  to  bear  doAvn.    The  resulting 


78 


GYNECOLOGIC    EXAMINATION    :mETHODS 


bulging  of  the  structures  gives  some  idea  of  liow  poorly  the  pelvic  floor  sup- 
ports the  organs,  provided  the  patient  really  bears,  down  when  she  thinks  she 
does.  The  downward  displacement  of  the  vaginal  walls  and  pelvic  diaphragm 
may  be  still  further  shown  by  introducing  the  two  examining  fingers  and 
pressing  backward  and  downward,  at  the  same  time  separating  the  fingers 
widely,  as  mentioned  in  testing  the  strength  of  the  pelvic  floor. 

When  the  patient  is  in  the  upright  posture,  this  downward  displacement 
of  the  vaginal  wall  is  of  course  more  marked,  particularly  in  cases  of  pro- 
lapse of  uterus  and  vaginal  walls.  But  it  is  rarely  necessary  to  examine  a 
patient  in  the  standing  posture,  for  the  diagnosis  as  to  the  character  and 
extent  of  her  trouble  may  usually  be  made  without  it. 


I''ig.    55.       Testing    the    pelvic    floor    by    the    two    index    fingers,    introduced    together    and    then    separated. 


Scars  or  Distortions  of  Vaginal  Wall  or  Perineum.  Sometimes  there  are 
deep  scars  running  up  the  vaginal  wall  at  the  site  of  tear,  indicating  a  sevei-e 
injury  of  the  pelvic  sling.  These  scars  may  extend  out  onto  the  perineum 
and  be  seen  in  the  inspection  already  mentioned. 

Thickness  of  Perineal  Body.  The  thickness  of  the  perineum  remaining 
may  readily  be  determined  by  catching  the  perineal  tissue  between  the  finger 
in  the  rectum  and  thumb  in  the  vagina.  A  membranous  perineum  (torn  in- 
ternally, but  not  much  on  the  skin  surface)  may  be  demonstrated  by  examin- 
ing Avith  a  finger  in  the  vagina  and  the  thumb  outside  over  the  perineum. 


DIGITAL   VAGINAL    EXAMINATION" 


79 


RECTOI 

Tenderness,  Induration,  Hemorrhoids,  Fistula,  Fissure 

Above  the  perineum  the  anterior  rectal  wall  is  closely  applied  to  the  pos- 
terior vaginal  Avail.  Turn  the  examining  fingers  so  that  the  palmar  surfaces 
are  directed  backvard,  and  palpate  the  rectum  (Fig.  56 j.  If  there  is  any  pain- 
ful affection  in  that  portion  of  the  rectum,  there  will  l)e  decided  tenderness. 
If  an  induration  is  felt,  determine  whether  it  is  a  distinct  mass  Avith  definite 
outlines  (foreign  body,  fecal  material,  tumor  in  rectum),  or  a  diffuse  infiltra- 
tion (inflammatory,  syphilitic,  tubercular,  malignant).  Very  frequently  firm 
fecal  masses  will  be  felt  through  the  posterior  vaginal  wall.     Sometimes  these 


Fig.     56.       Palpation     of     rectum     through    posterior 
vagina]    wall.      (Ashton — Practice    of   Gynecology.) 


Fis 


Method    of    everting   the    anal    tissues    for 
inspection. 


are  large  enough  to  cause  a  l^ulging  of  a  part  of  the  wall,  while  in  exceptional 
cases  they  are  so  large  as  to  interfere  decidedly  with  bimanual  examination. 
In  the  loAver  part  of  the  i-ectum  these  masses  cause  no  trouble  in  diagnosis, 
for  in  that  situation  their  character  is  easily  recognized.  In  the  upper  part  of 
the  rectum,  however,  and  in  the  sigmoid  region  such  a  mass  may  cause  con- 
fusion in  diagnosis,  for  it  may  reseml^le  a  prolapsed  ovary  or  an  inflammatory 
mass  in  the  cul-de-sac  or  about  the  tube. 

The  distinguishing  characteristics  of  a  fecal  mass  are  three:  (a)  it  is  not 
particularly  tender,  (b)  it  has  usually  a  putty-like  consistency  and  may  be 
dented,  the  dent  remaining,  and  (c)  it  may  sometimes  be  pushed  along  to  a 
different  position  in  the  boAvel.     In  a  doubtful  ease  the  bowels  should  be 


80 


GYNECOI.OGIC    EXAMINATION    METHODS 


moved  thovouohly  by  a  purgative  and  the  rectum  cleared  with  an  enema,  and 
the  patient  again  examined. 

In  a  patient  Avith  a  lax  pelvic  floor  the  anal  tissues  may  be  everted  by  pres- 
sure from  within  the  vagina  by  one  or  two  fingers,  as  indicated  in  Fig.  57. 
When  the  tissues  are  very  lax,  the  anus  may  be  opened  widely  and  the  rectal 


Fig.     58.       Indicating    the    amount     of    possible     eversion     of    anal     tissues    v/hen     the    pelvic     floor     is     las. 

(Dudley — Practice    of    Gynecology.) 

mucosa  exposed  (Fig.  58).  This  turning  out  and  examination  of  the  anal  tis- 
sues is  advisable  whenever  there  is  pain  on  defecation,  or  bleeding  or  other  evi- 
dence of  trouble  in  this  region.  In  this  wa}^  the  presence  or  absence  of 
hemorrhoids  or  fistula  or  fissure  may  be  determined. 


CERVIX  UTERI 

Position,  Size,  Shape,  Consistency,  Tenderness,  Mobility,  Attachments,  Direc- 
tion in  Which  it  Points,  Laceration  with  Eversion  of  Lips, 
Size  and  Shape  of  External  Os 

The  cervix  uteri  is  felt  at  the  upper  end  of  the  vagina  as  a  firm,  conical 
body,  projecting  through  the  upper  portion  of  the  anterior  Avail  (Figs.  1  and 
3).  It  is  distinguished  from  the  surrounding  vaginal  Avail  by  its  greater 
hardness. 


DIGITAL    VAGINAL    EXA:^riNATION  81 

Position  of  Cervix.  The  iioi-inal  position  of  the  cervix  is  from  three  to 
three  and  one-half  inches  from  the  vaginal  orifice.  The  fingers  are  carried 
toward  the  top  of  the  vagina  until  the  tip  of  the  finger  touches  the  cervix.  If 
the  vaginal  orifice  comes  well  up  to  the  upper  end  of  the  third  joint  of  the 
finger,  the  cervix  is  in  normal  position  (the  author  assumes  a  hand  of  average 
size,  with  index  finger  about  three  and  three-fourths  inches  long).  If  the 
cervix  is  encountered  by  the  finger  before  it  is  introduced  that  far,  the  cervix 
is  too  low.  If  not  encountered  at  that  point,  it  is  too  high.  Another  method 
of  determining  the  position  of  the  cervix  is  to  ascertain  if  it  is  above  or  beloAv 
the  level  of  the  ischial  spines,  for  normally  the  lower  margin  of  the  cervix  lies 
about  at  the  interspinal  line.  The  diagnostic  significance  of  abnormal  position 
of  the  cervix  is  given  in  Chapter  ii. 

In  cases  where,  after  examination  in  the  dorsal  posture,  it  is  still  uncertain 
as  to  whether  or  not  there  is  serious  descent  of  the  uterus,  the  patient  may 
be  examined  in  the  standing  posture.  The  patient  stands,  with  one  foot  slightly 
elevated  on  the  round  of  a  chair  or  on  a  small  stool,  while  the  examiner,  sit- 
ting on  a  chair  in  front  of  her,  makes  the  vaginal  examination.  In  this  pos- 
ture a  decided  descent  of  the  uterus,  which  might  disappear  Avhen  the  patient 
lies  down,  is  at  once  appreciable.  Examination  in  this  position  is  employed 
also  to  detect  the  ballottement  of  early  pregnancy  in  doubtful  cases.  Exami- 
nation in  this  posture,  however,  is  rarely  required,  for  in  almost  all  cases  the 
information  necessary  to  a  diagnosis  may  be  obtained  by  the  more  common 
methods  of  gynecologic  investigation. 

Size  and  Shape.  The  size  and  shape  of  the  cervix  varies  much  in  dif- 
ferent individuals,  and  in  the  same  individual  at  diiferent  periods  of  life.  In 
Avomen  who  have  never  been  pregnant  the  normal  cervix  has  the  shape  of  a 
rounded  cone  about  one  inch  wide,  and  projects  into  the  vagina  from  one-half 
to  three-quarters  of  an  inch.  The  external  os  is  small  and  round,  and  is  at  the 
flattened  apex  of  the  cone. 

In  certain  abnormal  cases  the  cervix  is  very  long  (an  inch  to  an  inch  and 
a  half)  and  pointed.  This  condition  is  known  as  conical  cervix.  It  is  fre- 
quently accompanied  by  a  very  small  external  os  ("pinhole  os"),  and  is  one 
cause  of  sterility. 

In  women  who  have  borne  children  the  cervix  is  larger  and  broader,  and 
comparatively  shorter.  The  os  is  a  transverse  slit  and  is  irregular  in  shape, 
and  may  be  large  enough  to  admit  the  finger-tip.  There  are  usually  small 
scars  and  irregular  depressions  from  lacerations  in  labor.  When  the  cervix 
has  been  severely  lacerated,  there  may  be  two  or  three  distinct  lips.  Again, 
it  may,  on  account  of  chronic  inflammation,  become  enlarged  to  two  or  three 
times  its  normal  size  and  may  be  felt  as  an  irregular  ball  at  the  top  of  the 
vagina. 

Consistency.  The  normal  cervix  is  like  hard  connective  tissue,  almo.st  as 
hard  as  tendon.     Its  consistency  is  closely  approached  by  that  of  the  end  of 


82  GYNECOLOGIC    EXAMINATION    METHODS 

the  nose  when  firmly  pressed  upon.  Durmg  pregnancy  the  cervix  softens, 
the  softening  beginning  at  the  lower  end  and  gradually  involving  more  and 
more  as  pregnancy  advances.  The  softening  is  so  marked  that  the  softened 
portion  is  sometimes  missed  entirely,  the  cervix  being  apparently  simply 
shortened.  This  is  what  gave  rise  to  the  former  idea  that  the  cervix  became 
gradually  shortened  as  pregnancy  advanced.  The  softened  portion  feels  like 
thick  velvet  or  a  fold  of  vaginal  wall  as  it  slips  back  and  forth  beneath  the 
examining  finger.  It  is  hard  to  describe  satisfactorily,  but  when  once  felt  is 
easily  recognized  afterward.  A  partial  idea  of  it  may  be  secured  by  the  fol- 
lowing experiment.  Cover  a  finger  with  a  piece  of  heavy  velvet  with  a  very 
thick  nap,  the  nap  side  out.  Then  shut  the  eyes  and  Avith  the  other  hand,  with 
the  fingers  usually  used  in  vaginal  examination,  endeavor  to  make  out  exactly 
the  thickness  of  the  nap  by  passing  the  fingers  over  it  with  varying  pressure 
and  in  different  directions.  First  make  firm  pressure  so  as  to  appreciate  the 
fingers  beneath,  then  make  light  pressure  so  as  to  estimate  the  thickness  of  the 
nap.  These  same  maneuvers  are  carried  out  in  appreciating  the  presence  and 
extent  of  marked  softening  of  the  cervix. 

This  softened  velvety  condition  of  the  cervix  is  very  characteristic  and 
should  ahvays  arouse  suspicion  of  pregnancy.  Some  softening  of  the  cervix 
is  found  in  certain  cases  of  inflammation  of  the  cervix,  and  also  in  cases 
where  its  circulation  is  interfered  with,  as  when  the  pelvis  is  filled  with  a 
tumor  or  with  a  mass  of  inflammatory  exudate,  or  where  there  is  marked  dis- 
placement of  the  uterus. 

Abnormal  hardening  of  a  portion  of  the  cervix  may  be  due  to  scar-tissue, 
to  cystic  disease,  to  a  fibroid  nodule  or  to  malignant  infiltration. 

Tenderness  of  Cervix.  The  cervix  is  much  less  sensitive  than  the  vaginal 
wall,  and  rarely  becomes  very  sensitive  even  when  diseased.  The  pain  com- 
plained of  when  the  cervix  is  pressed  upon  is  usually  due  to  the  pulling  upon 
inflamed  periuterine  structures,  by  the  resulting  movement  of  the  uterus. 

Mobility  of  Cervix.  Normally  the  cervix  is  freely  and  painlessly  movable 
for  a  short  distance  in  all  directions.  Its  range  of  mobility  may  be  dimin- 
ished by  scar-tissue  or  by  malignant  infiltration  in  the  upper  part  of  the 
vagina,  or  by  an  inflammatory  exudate  in  the  pelvis,  or  by  a  uterine  tumor 
or  by  any  pelvic  tumor  that  fixes  the  uterus.  Its  range  of  mobility  may  be 
increased  by  laceration  or  overstretching  of  the  supports,  posteriorly  or  an- 
teriorly or  laterally,  a  frequent  accompaniment  of  pelvic  floor  injuries. 

Attachment  of  Cervix.  Is  the  cervix  attached  or  fixed  to  the  pelvic  wall 
at  some  point  ?    If  so,  where  and  by  what  1 

Direction  of  Cervix.  Does  the  cervical  canal — i.  e.,  the  axis  of  the  cer- 
vix— point  across  the  vagina,  about  toward  the  coccyx,  as  it  should  (Figs.  1 
and  3)  ?  "When  you  find  the  cervix  pointing  along  the  vagina  toward  you,  do 
not  jump  at  the  conclusion  that  there  must  be  a  backward  displacement  of 


BIMANUAL   EXAMINATION"  83 

the  uterus.  It  may  he  tliat  otlier  rather  common  condition — anteflexion  of 
the  cervix. 

Laceration  of  Cervix,  Eversion  of  Lips.  The  presence  or  absence  of  this 
condition  is  determined  when  ascertaining  the  size  and  shape  of  the  cervix. 
For  the  various  conditions  thus  produced  see  Chapter  ii. 

Size  and  Shape  of  External  Os.  These  items  are  determined  by  palpa- 
tion of  the  OS  when  ascertaining  the  general  size  and  shape  of  the  cervix.  The 
various  conditions  of  the  external  os  are  shown  in  Chapters  ii  and  vi. 

PERICERVICAL  TISSUES 
Tenderness,  Induration 

The  tissues  about  the  cervix,  immediately  beneath  the  vaginal  Avail,  may 
be  palpated,  and  tenderness  or  induration  noted.  If  induration  is  present,  note 
whether  it  is  a  distinct  well-defined  mass  or  diffuse  infiltration  and  thicken- 
ing of  the  tissues. 

VAGINO-ABDOMINAL  EXAMINATION  (BIMANUAL) 

The  vagino-abdominal  examination  is,  as  its  name  implies,  an  examination 
from  the  vagina  and  the  abdomen  at  the  same  time.  The  pelvic  structures  are 
caught  between  the  fingers  in  the  vagina  and  the  fingers  over  the  abdomen, 
and  carefully  examined  by  indirect  touch  (Figs.  59,  60).  By  it  the  body  of 
the  uterus  is  located  and  outlined.  The  region  to  each  side  of  the  uterus  is 
palpated  and  also  the  space  back  of  the  uterus.  It  is  determined  if  there  is 
any  abnormal  mass  in  the  pelvis  or  if  there  is  any  area  of  marked  tenderness. 

To  the  beginner  in  gynecologic  work  this  important  bimanual  examina- 
tion is  often  unsatisfactory.  He  has  heard  a  great  deal  about  tubal  and 
ovarian  disease,  and  he  expects  to  feel  the  tube  and  ovary  at  once.  He  exam- 
ines a  patient,  or  several  patients,  and  can  feel  neither  tube  nor  ovary  if  they 
are  normal.  Then  he  is  discouraged,  and  thinks  that  he  has  learned  nothing 
from  the  examination.  And  probably  he  has  not  learned  much,  for  the  simple 
reason  that  he  was  feeling  for  something  that  he  could  not  feel,  and  did  not 
know  the  significance  of  what  he  did  feel.  Close  attention  to  the  details  of 
the  examination  will  prevent  this  unprofitable  experience. 

The  information  concerning  the  Bimanual  Examination  may  be  divided  as 
folloAvs: 

Palpation  of  Uterus — Position,  Size,  Shape,  Consistency,  Tenderness, 

^Mobility,  Attachments. 
Palpation  of  Tubo-ovarian  Region — Tenderness,  Mass  or  Induration. 
Palpation  of  other  Regions — Tenderness,  Mass  or  Induration. 


84 


GYNECOT.OGIC    EXAMINATION    METHODS 


General  Observations — Impoi'tance  of  the  Educated  Touch,  Tram 
One  Hand,  Use  Two  Fmgers,  Examme  Deeply  in  Pelvis,  May 
Draw  Down  Uterus,  Preferable  Position  for  Examiner,  Condi- 
tions in  Different  Patients,  Get  Intestines  out  of  the  Way,  Dimin- 
ish Tenderness. 


PALPATION  OF  BODY  OF  UTERUS 

Position,  Size,  Shape,  Consistency,  Tenderness,  Mobility,  Attachments 

Locating  the  Corpus  Uteri 

Steps.     The  locating  of  the  corpus  uteri  will  be  much  facilitated  by  pro- 
ceeding as  follows: 


Fig.  59.  liimanual  Examination,  showing  also 
the  disposition  of  outside  fingers  and  left  thumb. 
(Kelly — Ofcratk'c    Gynecology.) 


Fig.  60.  Showing  the  other  disposition  of  third 
and  fourth  fingers  along  the  gluteal  crease.  This 
allows  deeper  penetration  of  the  examining  fingers  in 
certain  exceptional  cases,  particularly  in  very  stout 
patients.      (Kelly — Operative   Gynecology.) 


1.  With  two  fingers  in  the  vagina,  locate  the  cervix  and  then  push  the 
cervix  backward  and  upA^'ard. 

2.  Then,  with  the  fingers  of  the  abdominal  hand  depressing  the  abdominal 
wall  into  the  depth  of  the  pelvis  back  of  the  uterus,  bring  the  fundus  uteri 
well  forward. 

3.  Then,  with  the  pressure  still  maintained  in  the  direction  indicated,  slip 
the  vaginal  fingers  in  front  of  the  cervix  (Fig.  61).  The  body  oljhe  uterus  is 
thus  caught  firmly  between  the  fingers  below  and  aliove,  and  may  be  clearly 
felt  and  outlined. 


BIMANUAL   EXAMINATION 


85 


Two  Common  Errors.  The  following  errors  are  made  so  often  b}'  students 
and  i^raetitioners  that  the  author  thinks  it  advisable  to  call  particular  atten- 
tion to  them. 

Error  1.  Depression  of  the  Abdominal  Wall  too  Close  to  the  Pubes.     If 

the  uterus  happens  to  be  far  forAvard,  this  causes  no  trouble,  but  if  the  uterus 
is  very  high,  as  it  frequently  is  from  a  fcAV  hours'  urine  in  the  bladder  or  other 
normal  or  abnormal  cause,  the  depression  of  the  wall  close  to  the  pubes  tends  to 
push  the  uterus  backward  (Figs.  62,  63).  Consequently  it  is  not  felt  between 
the  examining  fingers,  though  there  is  no  real  displacement,  or  was  none 
before  this  examination  was  begun. 

To  avoid  this  error,  depress  the  abdominal  wall  near  the  promontory  of 
the  sacrum,  about  midway  between  the  pubes  and  the  umbilicus  (Fig.  64).    In 


rig.   61.      Showing  the  third  step  in  the  palpation  of 
the  uterus.      (Montgomery — Practical  Gynecology.) 


Fig.  52.  Depression  of  the  abdominal  wall  too 
close  to  pubes.  Sectional  view.  (Ashton — Practice 
of  Gynecology.) 


particularly  difficult  cases  it  is  Avell  to  start  very  high  and  bring  the  fingers 
down  upon  the  sacral  promontory,  and  then  allow  them  to  slip  over  the  prom- 
ontory into  the  posterior  part  of  the  pelvis.  They  are  then  brought  forward 
until  the  body  of  the  uterus  is  felt  or  until  the  vaginal  and  abdominal  fingers 
are  so  closely  approximated  that  the  absence  of  the  uterus  from  that  part  of 
the  pelvis  is  demonstrated. 

Error  2.  Prequent  Shifting  of  the  Position  of  the  Abdominal  Fingers. 
Some  students  gouge  about  in  the  loAver  abdomen  in  various  directions  in  an 
effort  to  feel  the  fundus  uteri  with  the  abdominal  fingers.     This  is  likely  to 


86 


GYNECOLOGIC    EXAMINATION    METHODS 


make  the  examination  a  failure  in  a  normal  case  and  it  is  almost  certain  to  do 
so  in  a  difficult  ease.  Remember  that  tension  of  the  abdominal  wall  interferes 
with  the  examination  and  may  defeat  it  entirely.  Remember  also  that  the  ten- 
sion is  increased  by  frequent  movements  of  the  abdominal  fingers,  such  as 
placing  them  in  one  position  after  another  in  rapid  succession,  and  particu- 
larly by  endeavoring  to  gouge  in  rapidly  and  forcibly  in  various  parts  of  the 
pelvis  in  an  endeavor  to  overcome  the  resistance  of  the  wall.  Keep  in  mind 
that  most  of  the  effective  palpation  is  done  with  the  vaginal  fingers,  the 
principal  function  of  the  abdominal  fingers  being  to  bring  the  body  of  the 
uterus  within  reach  of  the  vaginal  fingers  and  then  hold  it  there  while  palpa- 


> 


Fig.    63.      Depression    of    abdominal    wall    too    close 
to    the    pubes.      Outside   view. 


Fig.    64.      Depression    of    abdominal    wall   at    the 
proper  height. 


tion  is  being  carried  out.     Get  clearly  in  mind. just  exactly  Avhat  movements 
are  necessary  to  best  palpate  the  uterus. 

In  order  to  avoid  this  error  just  mentioned,  place  the  abdominal  fingers  so 
that  the  depression  of  the  wall  will  be  into  the  back  part  of  the  pelvis,  and 
then  carry  the  fingers  by  steady  and  continuous  pressure  toward  the  desired 
region.  When  you  have  advanced  the  fingers  as  far  as  possible,  hold  them 
there  steadily  and  direct  the  patient  to  take  a  deep  breath  and  then  to  let  the 
breath  all  out.  As  expiration  takes  place,  the  fingers  may  be  carried  deeper 
into  the  pelvis — not  by  any  sudden  forcing  movement,  but  by  strong  steady 


BIMANUAL   EXAMINATION 


87 


pressure  that  does  not  excite  muscular  contraction'  and  resistance.  If  still 
the  fingers  are  not  deep  enough  in  the  pelvis,  the  same  movements  may  be  re- 
peated several  times.  Because  the  uterus  is  not  felt  at  once,  do  not  cease  the 
pressure  there  and  begin  to  depress  the  wall  at  some  other  place.     Start  the 


Fig.   65.      Explaining   one   condition   in   which   the  Fig.   66.      Search    is    then    made    in    the    posterior 

uterus  is  not  found   in  the  front  part   of  the  pelvis.         part  of  the  pelvis,  and  the  uterus  is  found  in  retro- 
(Ashton — Practice   of   Gynecology.)  version.      (Ashton — Practice  of  Gynecology.) 


Fig.  67.  Indicating  the  examination  findings  when  the  uterus  is  in  retroflexion.  Notice  the 
marked  angle  which  is  palpable  posteriorly  at  the  junction  of  the  cervix  and  corpus  uteri.  (Ashton — 
Practice    of    Gynecology.) 


88  GYXECOLOGIC    EXA^IIXATIOX    ^lETHODS 

fingers  in  the  right  direction  at  first  and  then  l^eep  them  going  in  that  direc- 
tion steadily,  firmly,  persistently,  Avithout  relaxing  the  pressure,  until  the 
depth  of  the  pelvis  is  reached  and  the  uterus  felt. 

In  the  subsequent  steps  of  the  palpation  of  the  uterus  the  slight  move- 
ment of  the  abdominal  fingers  that  is  necessary  to  bring  them  in  position  for 
good  counter-pressure  at  the  various  parts  of  the  uterus  may  usually  be  made 
without  relaxing  the  pressure,  as  the  skin  is  loose  enough  to  be  slipped  about 
over  the  underlying  structures. 

If  the  body  of  the  uterus  is  not  found  in  front  of  the  cervix  (Fig.  65 ),  then 
search  behind  the  cervix  (Figs.  66,  67)  and  then  to  each  side  of  it.  If  the 
patient  has  no  mass  obstructing  the  pelvis  and  no  extreme  tension  of  the 
abdominal  vail,  the  body  of  the  uterus  should  be  distinctly  made  out. 

Facts  to  Determine 

AYhen  the  body  of  the  uterus  has  been  located,  then  fix  in  mind  the  follow- 
ing facts  concerning  it: 

1.  Position  of  the  Corpus  Uteri.  Is  it  in  anterior  position,  as  it  should 
be,  or  is  it  displaced  backward  or  down  to  one  side  ? 

2.  Size  of  Corpus  Uteri.  Is  it  apparently  normal  in  size  (about  three 
inches  long)  or  is  it  as  large  as  the  fist,  or  as  large  as  a  child's  head?  Figs. 
68  and  69  indicate  the  method  of  palpating  the  margin  of  the  uterus  and  also 
the  method  of  determining  its  A\-idth  by  separation  of  the  vaginal  fingers. 

3.  Shape  of  the  Corpus  Uteri.  Is  it  approximately  pear-shaped  and  of 
regular  contour,  or  is  it  distorted  by  fibroids  or  other  tumors? 

4.  Consistency  of  Corpus  Uteri.  Is  it  apparently  a  firm,  solid  body  or 
does  it  contain  fluid,  or  are  there  hard  nodules  in  it,  or  is  there  marked 
softening  ? 

5.  Tenderness  of  Corpus  Uteri.  Does  pressure  on  the  uterus  cause  pain  or 
does  the  attempt  to  move  it  cause  pain? 

6.  Mobility  of  Corpus  Uteri.  Can  the  uterus  be  moved  freely  up  and 
down,  to  right  and  left,  forward  and  backward,  or  is  it  fixed  more  or  less 
firmly  by  an  inflammatory  exudate  or  by  a  tumor  ? 

7.  Attachment  of  Corpus  Uteri.  Does  the  uterus  seem  to  be  attached  or 
fixed  to  the  pelvic  wall  at  some  point  ?    If  so,  where  and  by  what  ? 

In  determining  the  various  facts  about  the  uterus,  material  assistance 
is  given  in  some  cases  by  separating  the  fingers  laterally,  as  indicated  in  Fig. 
69,  or  by  separating  them  antero-posteriorly,  placing  one  finger  behind  and 
the  other  in  front  of  the  cervix. 

AYhen  it  is  impossible  to  reacli  the  various  parts  of  the  uterus  sufficiently 
to  obtain  the  necessary  information,  the  cervix  may  l)e  caught  Avith  a  tenacu- 
lum forceps  and  the  uterus  pulled  somewhat  downward  (Fig.  70).  Care 
should  be  taken,  however,  not  to  pull  the  uterus  down  vei-y  far,  because  of 
the  danger  of  overstretching  the  utcro-sacral  ligaiuents. 


BIMANUAL    EXAMINATION 


89 


PALPATION  OF  LATP:RAL  EEGIOXS  OF  PELVIS 
Tubes  and  Ovaries,  Mass,  Induration,  Tenderness 

In  this  region,  on  each  side,  lies  the  lai-ge  area  of  connective  tissue,  beside 
the  cervix  and  lower  part  of  the  corpus  uteri.  Here  induration  from  inflam- 
mation or  other  cause  is  felt  at  once,  Ioav  about  the  cervix,  just  under  the 
vaginal  wall.  Higher,  beside  the  uterus,  lie  the  Fallopian  tube  and  the  ovary. 
They  are  near  the  upper  part  of  the  broad  ligament  and  so  close  together  that 
ordinarily  it  is  impossible  to  say,  simply  from  the  position  of  a  mass  there, 
Avhether  it  springs  from  the  tube  or  from  the  ovary.  Hence  the  region  is 
spoken  of  as  the  "tubo-ovarian"  i-egion,  as  both  organs  lie  there.  The  tubo- 
ovarian  region  lies  high,  and  to  palpate  it  satisfactorily  requires  special  care. 


Steps  in  Palpation  of  the  Lateral  Regions 

In  palpating  the  tubo-ovarian  region  of  the  left  side,  proceed  as  folloAvs: 
1.  Place  the  tips  of  the  vaginal  fingers  to  the  left  side  of  the  cervix,  and 
then  push  them  backwai-d  and  outAvard  and  upward  as  far  as  possible. 


Fig.  68.  Palpating  the  margin  of  the  uterus,  to 
rleterniine  enlargement  or  irregularity.  (Edgar — 
Practice   of  Obstetrics.) 


Fig.  69.  Estimating  the  width  of  the  uterus  by 
separating  the  vaginal  fingers  so  that  one  goes 
to  each  side  of  the  uterus.  (Edgar — Practice  of 
Obstetrics.) 


In  order  to  carry  the  finger-tips  sufficiently  far  into  the  posterior  lateral 
area  of  the  pelvis,  it  is  necessary  to  push  the  perineum  for  some  distance  into 
the  pelvis.  This  is  best  accomplished  usually  by  utilizing  the  force  of  the 
body  muscles,  transmitted  to  the  elboAV  either  through  the  knee  (Figs.  71, 
72),  with  the  foot  on  a  small  stool,  or  through  the  iliac  crest  (Fig.  73).     This 


90 


GYNECOLOGIC   EXAMINATION    METHODS 


leaves  the  arm  muscles  free  for  the  deep  delicate  manipulation  necessary  to 
accurate  palpation  of  the  pelvic  contents. 

2.  With  the  abdominal  fingers  locate  the  anterior  superior  spine  of  the 
ilium  on  the  left  side  and  then  bring  the  fingers  directly  inward  (not  down- 
ward toward  the  pubes,  but  directly  inward  or  slightly  upward)  toward  the 
median  line  for  about  two  inches  (Fig.  74) , 

3.  Then,  at  that  point,  depress  the  abdominal  wall  into  the  posterior  part 
of  the  side  of  the  pelvis  (Figs.  75,  76)  until  the  tips  of  the  abdominal 
fingers  come  close  to  the  tips  of  the  vaginal  fingers.  This  brings  the  fingers  near 
to  each  other  back  of,  or  at  least  in  the  region  of,  the  tube  and  ovary  (Fig.  77). 

4.  If  the  adnexa  are  not  felt  in  the  back  part  of  the  pelvis,  then  bring 


Fig.   70.      Drawing  the  uterus  down   with   a  tenaculum   forceps   to   brihg   it  within   reach   of 
the   examining   fingers.      (Dudley — Practice   of   Gynecology.) 


the  fingers  of  the  two  hands,  held  in  the  same  relation  to  each  other,  slowly 
downward  toward  the  pubes  (Fig.  78).  In  this  Avay  the  tube  and  the  ovary 
are  made  to  pass  between  the  examining  finger-tips  and  may  be  felt  if  de- 
cidedly enlarged.  The  fingers  are  then  carried  on  downward  and  tOAvard  the 
median  line  in  order  to  palpate  the  front  part  of  the  pelvis. 

By  proceeding  gently,  so  as  not  to  excite  contraction  of  the  abdominal 
muscles,  and  at  the  same  time  steadily  pressing  the  two  sets  of  fingers  toward 
each  other,  a  little  with  each  expiration,  the  finger-tips  may  be  brought  almost 
together  in  the  various  parts  of  the  pelvis. 

In  these  manipulations  the   palpation  proper  is   made  principally  with 


BIMANUAL   EXAMINATION  91 

the  vaginal  fingers,  the  abdominal  fingers  serving  simpl}-  to  push  the  struc- 
tures down  within  reach  of  the  fingers  below. 

A  common  error  is  to  bring  the  tips  of  the  examining  fingers  together  too 
close  to  the  pubes ;  hence  the  palpation  is  of  the  tissue  in  front  of  the  tube  and 
ovary,  even  if  they  are  in  normal  position.  It  must  be  kept  in  mind  also  that 
the  tube  and  ovary  are  likely  to  be  displaced,  especially  if  diseased,  and  the 
displacement  is  nearly  always  backward;  hence  the  importance  of  getting 
far  back  in  the  side  of  the  pelvis  when  endeavoring  to  accurately  palpate 
these  structures. 

In  order  to  avoid  this  error,  be  certain  that  the  point  of  depression  of  the 
abdominal  wall  is  Avell  above  the  tubo-ovarian  region,  so  that  when  depressed 
into  the  pelvis  it  will  lie  back  of  the  tube  and  ovary. 

In  palpating  the  right  side  of  the  pelvis  follow  the  same  directions,  sub- 
stituting ''right"  for  ''left"  (Fig.  79). 

Facts  to  Determine 

In  the  exploration  in  the  tubo-ovarian  region  take  particular  care  to 
search  for: 

Tube  and  Ovary — Usually  not  felt  if  normal ; 

Abnormal  Mass — Enlarged  Tube  or  Ovary,  Exudate,  Tumor; 

Induration — Inflammatory  Infiltration  or  Exudate,  Adhesions,  Scar- 
tissue  : 

Tender  Area — Normal  Sensitiveness  of  Ovaries,  Inflammation,  Hyper- 
esthesia, Tenderness  from  other  cause. 

Tube  and  Ovary.  In  many  cases  the  normal  tube  and  ovary  can  not  be  dis- 
tinctly felt,  even  by  the  experienced  examiner,  and  the  inexperienced  Avill  find 
it  difficult  even  in  comparatively  easy  cases.  When  the  tube  or  ovary  is  de- 
cidedly enlarged,  it  can  be  felt  to  slip  between  the  examining  fingers  as  a 
distinct  thickening  or  as  a  small  rounded  mass. 

After  locating  the  adnexa,  as  above  described,  it  is  sometimes  advantageous 
to  try  to  trace  the  tube  out  from  the  uterus.  The  fundus  uteri  is  located,  the 
examining  fingers  (vaginal  and  abdominal  making  united  counter-pressure) 
pass  to  the  upper  outer  angle,  and  then  feel  for  the  tube  as  it  leaves  the  uterus 
and  runs  along  the  top  of  the  broad  ligament.  The  best  place  to  locate  it 
usually,  when  not  abnormally  indurated,  is  just  beyond  the  angle  of  the 
uterus.  It  is  a  much  firmer  cord  here  than  farther  out,  where  the  cavity  be 
comes  large  and  the  tube  soft. 

The  normal  Fallopian  tube  may  be  felt  in  a  suitable  case  (thin  patient  with 
relaxed  abdominal  Avail  and  relaxed  pelvic  floor),  in  the  position  indicated, 
as  a  small  soft  cord  about  the  size  of  a  slate  pencil.  It  presents  very  much  the 
consistency  of  a  piece  of  rubber  tubing.  It  may,  in  a  suitable  ease,  be  traced 
outward  and  is  then  lost  in  a  region  of  the  ampulla,  where  the  tube  becomes 
very  soft  and  the  ovary  comes  into  prominence  as  a  soft  rounded  movable 


92 


GYNECOLOGIC    EXAMINATION    METHODS 


body,  a  trifle  larger  than  the  end  of  the  thnnib  and  sensitive  to  pressure. 
When  the  tube  is  inflamed  it  becomes  harder  and  larger,  and  is  more  easily 
felt.  It  then  feels  very  much  like  a  rather  firm  piece  of  rubber  tubing  of  about 
the  size  of  a  lead-pencil  or  larger,  extending  outward  from  the  angle  of  the 
uterus,  Avith  irregular  curves  and  bendings  and  enlargements.  From  this 
size  it  may  enlarge  to  a  mass  that  fills  all  that  side  of  the  pelvis.  Usually, 
however,  when  the  inflammation  is  at  all  severe,  adhesions  or  plastic  exudate 
surround  the  tube  and  ovary,  binding  them  and  the  surrounding  structures 
together  in  one  mass  and  making  their  separate  differentiation  impossible. 


Fig.    71.      Invagination    of   the    perineum    and   pelvic    floor,    the    force    being    transmitted    through    the    knee. 


If  on  examination  the  pelvic  tissues  are  all  soft  and  yielding,  and  no  par- 
ticular pain  is  caused  by  the  palpation,  you  may  be  certain  that  the  tubes  and 
ovaries  are  not  seriously  diseased,  though  you  may  not  have  felt  them. 

Mass  in  Lateral  Part  of  Pelvis.  The  ])elvie  tissues,  with  the  exception 
of  the  uterus,  are  soft  and  yielding,  and  any  fii-m  body  may  be  felt  through 
them,  either  a  tumor  or  an  inflammatory  exudate  or  a  firm  blood-clot.  Fluid 
blood  or  serous  exudate  can  not  be  felt  unless  it  is  incapsulated.  If  a  mass 
is  found  to  either  side  of  the  uterus,  determine  concerning  this  mass  the  same 
facts  that  you  did  concerning  the  uterus — namely,   its  position,   size,   shape, 


BIiMANlTATi   EXAMINATION 


93 


consistency,  tenderness,  in()l)ility  and  attachments.  Detei-iiiiiie  particularly 
Avhether  or  not  it  is  attached  to  the  utei'us,  and,  if  so,  whether  by  a  bi'oad 
attachment  or  by  a  narrow  one. 

Induration  in  the  Lateral  Part  of  Pelvis,  In  some  cases  Avhere  there  is  no 
distinct  mass  felt,  there  is  a  very  definite  hardening  of  tissues  at  some  point. 
Instead  of  the  tissues  being  soft  and  pliable,  and  easily  pushed  before  the  ex- 
amining finger,  as  they  are  normally,  there  is  a  stillness  and  fixation  and 
resistance,    as   though   there   were   infiltration   and    thickening,    and   the   struc- 


Fig.    72.      Use    of   this   maneuver    for    invaginating   the    pelvic    floor    in    the    deep    bimanual    palpation. 

tures  beyond  can  not  be  satisfactorily  palpated.  This  resistance  and  fixation  of 
tissue  without  a  well-defined  mass  is  designated  b}-  the  term  "induration." 
It  may  be  due  to  infiltration  (inflammatory,  tubercular,  malignant)  of  the 
tissues,  to  inflammatory  exudate  or  surfaces,  to  adhesions,  to  scar-tissue  or  to 
a  tumor  not  yet  developed  far  enough  to  form  a  distinct  mass. 

Tender  Area  in  Lateral  Part  of  Pelvis.  The  ovaries  are  usually  rather 
sensitive  on  bimanual  palpation,  and  allowance  must  be  made  for  this  normal 
sensitiveness  when  estimating  the  diagnostic  significance  of  tenderness  in 
this  region. 


94 


GYNECOLOGIC   EXAMINATION    METHODS 


Fig.    IZ.      Transmitting   the    force    to    the    elbow    through   the    iliac    crest    in    deep    bimanual    palpation. 


Fig.   74.     Palpation     of    the    left    lateral    region.  Fig.   75.     Palpation    of    the    left    lateral    region. 

Placing   the    fingers    of    the    abdominal    hand.      They  Depressing     the     abdominal     wall     deeply     into     the 

should   be    on   a   level    with,    or   a   little    above,   the  pelvis, 
anterior   superior   spine    (indicated    by    the    cross). 


BIMANUAL    EXAMINATION 


95 


Tenderness  on  palpation  may  accompany  almost  any  pathologic  condi- 
tion in  the  pelvis,  but  it  is  especially  marked  in  inflammatory  trouble,  in 
peritoneal  irritation  from  blood  in  the  peritoneal  cavity  and  in  neuralgic  af- 
fections of  the  pelvis. 


Fig.    1(>. 


A    view    from    another    direction,    showing    the    marked    depression     of    the    abdominal     wall    in 
deep     pelvic    palpation. 


PALPATION  OF  OTHER  REGIONS 

In  the  same  way,  as  already  described,  careful  exploration  is  made  of: 

Posterior  Part  of  Pelvic  Cavity — Tenderness,  Induration,  Mass; 

Anterior  Part  of  Pelvic  Cavity — Tenderness,  Induration,  Mass; 

Ureteral  Regions — Tenderness,  Induration,  Mass; 

Pelvic  Nerve  Trunks — Tenderness ; 

Lower  Abdomen — Tenderness,  Tension,  Induration,  Mass. 

If  a  mass  is  found,  determine  as  accurately  as  possible  its  position,  size, 
shape,  consistency,  tenderness,  mobility  and  attachments. 

The  method  of  determining  whether  a  mass  is  attached  to  the  uterus,  and. 
if  so,  how  intimately,  is  shown  in  Figs.  80  and  81,  Avhere  the  sulcus  between 
the  uterus  and  the  mass  is  being  palpated  to  determine  its  depth.  In  the  case 
of  a  tumor  with  a  long  pedicle  it  is  well  to  have  an  assistant  hold  the  tumor 
up  in  the  abdomen  out  of  the  way,  while  the  examiner,  by  bimanual  palpation. 


96  GYNECOT.OGIC    EXA^riNATION    ^[ETHODS 

feels  Avhether  or  ]iot  there  is  any  comieetion  Avith  the  uterus  or  appendages. 
Also,  the  uterus  may  be  caught  Avith  a  tenaculum  forceps  and  pulled  down- 
ward (Fig.  102),  assisting  still  further  in  palpation.  Another  point  is  that  in 
the  case  of  a  broad  attachment  to  the  uterus  the  mass  and  uterus  move  as  one 
body,  whereas  with  a  long  attachment  the  two  may  be  moved  separately. 

In  palpating  the  interior  part  of  the  pelvis,  if  the  body  of  the  uterus 
is  not  felt  in  front  and  still  the  vaginal  and  abdominal  fingers  can  not  be 
brought  Avell  together,  have  the  patient  pass  the  urine,  and  then  examine 
again.  If  the  patient  can  not  urinate,  or  does  not  seem  to  empty  the  blad- 
der well,  she  may  be  catheterized.  A  spontaneous  urination  in  the  upright 
posture  empties  the  bladder  better,  and  is  safer  than  catheterization,  which 
may  be  folloAved  by  cystitis.     A  partly  filled  bladder  is  not  felt  as  a  distinct 


Fig.     n.       The    ovary    caught    between    the    examining     fingers.       (Ashton — Practice     of     Gynecology.) 

mass,  and  yet  there  may  be  half  a  pint  or  more  of  urine — enough  to  make  the 
palpation  very  unsatisfactory.  The  peculiar  thing  about  this  condition  is 
that  there  is  nothing  to  indicate  it,  except  the  difficulty  in  locating  the  body 
of  the  uterus  in  deep  palpation.  No  mass  is  felt  and  the  tissues  are  all  soft 
and  yielding  and  there  is  no  particular  pain.  The  fingers  seem  to  sink  into 
the  pelvic  tissues  well,  but  for  some  unaccountable  reason  the  uterus  is  dif- 
ficult to  feel.  It  seems  too  far  back  in  the  pelvis  and  yet  Avhen  you  try  to 
bring  the  fingers  together  in  front  of  it,  they  do  not  come  together  aa'cU.  When 
such  a  condition  is  encountered  in  an  apparently  normal  abdomen  (no  marked 
obesity  or  musculai'  tension)  it  is  probably  due  to  a  collection  of  urine  in  the 
bladder  or  to  intestinal  coils  in  the  pelvis.     If  it  does  not  disappear  after  the 


bimanuaIj  examination 


97 


bladder  is  evacuated,  then  elevate  the  patient's  hips,  to  get  the  tympanitic 
intestinal  coils  out  of  the  pelvis.  The  bladder  and  other  tissues  in  front  of  the 
uterus  should  be  palpated  (Fig.  62)  to  determine  if  there  is  any  mass  or  any 
marked  tenderness. 

The  region  of  the  ureter  on  either  side  is  an  interesting  area  which  is 
usually  overlooked  in  pelvic  palpation.  The  ureter  extends  on  each  side  from 
the  base  of  the  bladder  backward,  outward  and  upward,  about  half  an  inch 
from  the  cervix  uteri.  Ordinarily  it  is  not  felt.  In  a  suitable  case,  however, 
it  may  be  felt  as  a  rather  indefinite  cord  or  line  of  tension,  extending  from 


Fig.    78.      The    abdominal    fingers    moving    downward. 


the  base  of  the  bladder  in  the  direction  indicated.  Fig.  82  indicates  the  method 
of  palpating  this  region.  If  inflamed,  the  ureter  is  tender  on  pressure.  If 
infiltrated  and  thickened,  it  is  easily  felt.  If  a  stone  is  lodged  in  the  lower 
poi'tion  of  the  ureter,  it  may  be  felt.  In  this  Avay  the  author  Avas  able  to  de- 
termine definitely  that  a  stone  Avas  lodged  in  the  left  ureter,  a  short  distance 
from  the  bladder,  in  the  case  of  a  pregnant  A\oman  Avith  such  sudden  severe 
pain  and  threatening  symptoms  that  it  Avas  at  first  feared  that  the  trouble 
Avas  rupture  of  an  extrauterine  pregnancy.  The  patient  eventually  recovered 
and  carried  the  child  to  term. 

If  much  inflammation  has  taken  place  about  a  stone  or  an  infected  por- 
tion''of  the  ureter,  there  may  be  considerable  periui-eteral  infiltration  that  in 


98 


GYXECOLOGIC    EXAMIXATIOX    METHODS 


a  measure  obscures  the  ureter,  and  gives  the  signs  simply  of  a  cellulitis  at  that 
side  of  the  uterus  and  extending  toward  the  bladder.  A  cellulitis  associated 
with  persistent  bladder  symptoms  should  be  carefully  investigated,  with  the 
idea  that  it  may  come  from  the  ureter.  Determine  if  the  induration  runs  into 
the  region  of  the  ureter  and  if  there  is  tenderness  farther  up  along  the  ureter 
or  in  the  kidney,  or  if  the  urine  gives  evidence  of  disease  in  the  urinary  tract. 
In  a  considerable  proportion  of  the  cases  presenting  persistent  bladder  irri- 
tability and  classed  as  chronic  cystitis,  the  trouble  is  really  located  in  the 
ureter.  Inflammation  or  tuberculosis  of  the  lower  part  of  the  ureter  gives 
symptoms  very  closely  resembling  chronic  cystitis. 


Fk 


79.      Palpating    right    tubo-ovarian    region. 


In  cases  where  pelvic  neuralgia  or  neuritis  is  suspected,  palpate  the  pelvic 
nerve  trunks  (Figs.  83  and  84).  Sometimes  the  pelvic  tenderness,  Avhich  at 
first  seems  widespread,  may  l)e  localized  in  its  greatest  intensity  along  the 
nerve  trunks  of  one  or  both  sides.  These  may  be  reached  by  deep  palpation 
per  vaginam  or  per  rectum.  • 


GENERAL  OBSERVATIONS  ON  BIMANUAL  EXAMINATION 

It  may  seem  hardly  worth  Avhile  to  take  the  trouble  to  make  out  all  these 
little  points  in  regard  to  the  uterus  or  a  mass  beside  the  uterus,  but  it  is  worth 
while,  and  the  farther  one  advances  in  diagnosis  the  more  he  appreciates  this 


BIMANUAL   EXAMINATION 


99 


fact.  The  ability  to  make  a  correct  diagnosis  in  deep  seated  pelvic  disease 
depends  largely  on  the  ability  to  answer  the  above  questions  correctly,  and 
until  one  can  determine  facts  as  above  indicated,  in  regard  to  the  uterus  or 
other  pelvic  mass,  one's  diagnosis  is  simply  a  guess  and  not  a  diagnosis  at  all. 

Importance  of  the  Educated  Touch 

The  author  desires  to  emphasize  the  importance  of  training  the  hands — of 
acquiring  the  "tactus  eruditus."  The  following  quotation  from  an  article  by 
the  author  on  the  subject  brings  out  this  point:  ''The  multiplication  of  in- 
struments for  diagnostic  purposes  has,  to  some  extent,  obscured  the  importance 
of  the  educated  touch.     The  beginner  in  gynecologic  work  is  bewildered  by 


Fig.     80. 


Method    of    determining    how     intimately    a    mass    is    attached    to     the     uterus, 
sulcus     between     the     two.        (Kelly — Operative     Gynecology.) 


Palpating    the 


the  great  variety  of  specula,  tenacula  and  other  instruments  for  diagnosis, 
and  he  is  accordingi}^  impressed  with  the  idea  that  the  principal  thing  is  to 
learn  how  to  use  instruments,  and  then  to  use  them  on  every  occasion.  One 
of  the  first  duties  of  a  teacher  in  gynecology  is  to  displace  this  erroneous  idea 
by  showing  the  importance  of  the  use  of  the  hands.  Most  of  the  serious  dis- 
eases of  women  affect  structures  that  lie  beyond  the  reach  of  sight.  To  the 
teacher  falls  the  duty  of  directing  the  student's  efforts  in  such  a  way  that  he 
will  acquire  the  ability  to  distinguish  these  intrapelvic  conditions  in  the  only 
way  that  such  conditions  can  be  distinguished,  namely,  by  touch.  After  the 
student  has,  by  lectures,  supplemented  by  charts  and  demonstrations,  been 


100 


GYNECOLOGIC    EXAMINATION    METHODS 


helped  to  form  a  mental  picture  of  tlie  normal  organs — their  position,  size, 
shape,  structure  and  relations — then  comes  the  task  of  helping  him  to  recog- 
nize such  conditions  by  the  sense  of  touch.  This  is  not  a  matter  of  a  few  days. 
It  takes  Aveeks  and  months  of  patient  work  and  many  careful  examinations, 
to  be  able  to  recognize  normal  conditions.  The  abdominal  wall  and  the  vaginal 
Avail  intervene  between  the  examining  fingers  and  the  important  organs.  These 
intervening  structures  vary  so  much  in  thickness,  in  consistency,  in  tension 
and  in  sensitiveness,  that  there  is  infinite  A-ariety  in  the  facility  Avith  Avhich  the 
organs  may  be  outlined.  Again,  the  organs  themseh-es  vary  much  Avithin  nor- 
mal limits,  in  different  individuals  and  in  the  same  indiAndual  at  different 
times. 

"The  beginner  must  learn  to  read  the  conditions  first  by  learning  the 


Fig.  81.  Determining  what  attaclinient  there  is  between  the  uterus  and  a  cyst  back  of  it. 
The  uterus  is  caught  between  the  hands  and  brought  forward  and  the  examining  fingers  are 
crowded     in    between     the     uterus    and    the    mass.       (Ashton — Practice     of     Gynecology.) 

separate  letters,  so  to  speak,  and  then  learning  Avhat  certain  groupings  of  let- 
ters mean.  The  separate  items  that  must  be  recognized  in  this  examination 
are  the  position,  size,  shape,  consistency,  tenderness,  mobility  and  attachments 
of  the  organs.  This  takes  much  time  and  patience  and  Avell  directed  efforts 
through  many  examinations.  It  can  not  be  learned  from  lectures.  It  can  not 
be  learned  by  seeing  someone  make  examinations  and  applications.  It  can  be 
learned  only  through  repeated  bimanual  examinations  by  the  student  him- 
self, under  competent  instruction.  Hence  the  importance  of  the  clinical  por- 
tion of  a  gynecologic  course. 

"Though  it  takes  considerable  time  to  learn  to  recognize  normal  condi- 
tions, the  time  is  Avell  spent,  for  no  real  progress  is  possible  Avithout  this 


BIMANUAL   EXAMINATION 


101 


knowledge.  The  normal  must  be  known  before  the  abnonnal  can  be  appre- 
ciated. This  is  self-evident  and  yet  how  many  students  at  graduation,  and 
physicians  long  after  graduation,  find  it  difficult  to  feel  more  than  the  vaginal 
walls  and  cervix. 

''In  the  recognition  of  pathologic  conditions,  the  same  points  must  be 
considered  (position,  size,  shape,  consistency,  tenderness,  mobility  and  attach- 
ments), and  this  information,  supplemented  by  the  history,  determines  the 
diagnosis.  This  determination  of  the  particular  pathologic  conditions  pres- 
ent is  accomplished  almost  altogether  by  the  hands,  either  in  the  ordinary 
bimanual  examination  oi-  in  the  examination  under  anesthesia. 


Fig.   82.     Palpating   the    region    of    the    right    ureter.      (Ashton — Practice    of    Gynecology.) 


*'I  do  not  wish  to  minimize  the  value  of  diagnostic  instruments  (specula, 
sounds,  curets,  etc).  They  are  often  helpful  and  in  some  cases  indispensable 
to  a  positive  diagnosis,  and  their  use  should  not  be  neglected.  But  I  want  to 
emphasize  the  fact  that  in  gynecologic  examinations  generally,  instruments 
are  of  secondary  importance  and  only  supplemental  to  the  trained  hand." 

Take  every  opportunity  to  educate  the  fingers  to  appreciate  as  accurately 
as  possible  the  various  conditions  found  in  the  pelvis.  When  examining  a 
suitable  case,  outline  the  uterus  and  all  the  pelvic  structures  as  clearly  as  you 
can,  even  if  not  necessary  to  the  diagnosis  in  that  particular  case.  Each  care- 
ful examination  made  serves  to  educate  the  fingers,  or  rather  serves  to  educate 
the  mind  to  appreciate  what  is  between  the  fingers,  and  prepares  you  to  make 
out  the  exact  conditions  in  difficult  cases. 


102 


GYNECOLOGIC   EXAMINATION    METHODS 

Train  One  Hand 


In  the  bimanual  examination,  it  is  well  to  train  one  hand  for  the  vaginal 
manipulations.  For  this  purpose,  either  the  right  or  the  left  hand  may 
be  selected,  as  the  examiner  finds  more  convenient.     The  author  uses  the  left, 


Deep  epigastric  . 
'    '     femoral  riiiK 
Obtur    art     '  Obtur  foramen 


art-  art.  .orrh.  arteries  tirethr 


Fig.  S3.  Showing  the  exact  situation  of  the  large  nerve  roots  in  the  pelvis.  In  the  illustra- 
tion the  large  nerve  roots  appear  a  shade  darker  in  color  than  the  other  structures.  (Kelly — 
Operative    Gynecology.) 


Fig.    84.      Palpating    the    pelvic    nerve    trunks    per    rectum.       (Dudley — Practice    of    Gynecology.) 


BIMANUAL    EXAMINATION  103 

leaving  the  right  free  for  the  abdominal  palpation  and  for  the  handling  of 
instrnments.  The  advantage  of  nsing  the  same  hand  in  vaginal  manipnlations 
in  practically  all  cases,  is  that  the  power  of  discrimination  by  the  fingers  of 
that  hand  increases  as  more  and  more  examinations  are  made.  At  the  same 
time,  the  abdominal  hand  becomes  accustomed  to  the  abdominal  manipulations 
and  as  the  examining  hands  are  in  practically  the  same  relation  in  every  case, 
deviations  from  the  normal  are  more  readily  recognized  and  more  accurately 
defined  than  if  the  two  hands  were  used  indiscriminately  and  hence  in  different 
i-elations.  This  is  especially  true  when  the  examiner  has  the  advantage  of 
only  a  limited  number  of  examinations. 

In  exceptional  cases,  it  is  an  advantage  to  use  first  one  hand  and  then  the 
other  for  vaginal  palpation.  In  some  cases,  the  right  side  of  the  pelvis  can  be 
explored  better  with  the  fingers  of  the  right  hand  and  the  left  side  with  the 
fingers  of  the  left  hand.  /        ;  ,  .      / 


Use  Two  Fingers 


/      j^X<^^ ^^^^<^^r 


Use  two  fingers  in  the  vagina  when  the  vaginal  opening  is  large  enough  to 
permit  their  use  without  pain.  A  deeper  and  more  accurate  examination  can 
be  made  with  two  fingers  (index  and  middle  finger)  than  with  the  index  finger 
alone.  The  upper  part  of  the  vagina  is  capacious.  The  only  difficulty  is  at 
the  vaginal  entrance.  By  lubricating  the  fingers  well,  and  depressing  the  peri- 
neum and  working  carefully,  the  two  fingers  may  be  used  without  discomfort 
in  practically  all  parous  women,  and  in  most  non-parous  women  who  have 
been  married. 

Examine  Deeply  in  Pelvis 

In  many  cases,  in  order  to  palpate  the  posterior  part  of  the  pelvis  and  par- 
ticularly to  satisfactorily  palpate  the  tubo-ovarian  regions,  the  vaginal  fingers 
must  reach  farther  than  their  length  will  permit.  The  extra  reach  is  secured 
by  carrying-  the  perineum  into  the  pelvis  (invagination  of  the  pelvic  floor)  by 
strong  steady  pressure  inward.  The  soft  structures  closing  the  pelvic  outlet 
can  be  carried  for  a  considerable  distance  inward  without  particular  discom- 
fort to  the  patient,  provided  all  the  muscles  are  relaxed.  In  parous  women, 
from  one  to  two  inches  may  usually  be  thus  added  to  the  effective  length  of 
the  examining  fingers. 

The  force  required,  while  not  great,  is  likely,  if  exerted  by  the  arm 
muscles  alone,  to  interfere  Avith  delicate  palpation  by  the  examining  fingers. 
It  adds  much  to  the  effectiveness  of  the  examination  to  exert  this  pressure 
by  the  body  muscles,  leaving  the  arm  muscles  free  for  the  internal  palpation 
movements.  This  may  be  accomplished  either  by  placing  the  left  foot  (when 
examining  with  the  left  hand)  on  a  stool  or  chair-round  and  resting  the  elboAV 
on  the  knee  (Figs.  71,  72),  or  by  letting  the  elbow  rest  against  the  hip  (Fig.  73). 


104  GYNECOLOGIC    EXAMINATION    METHODS 

May  Draw  the  Uterus  Down 

It  is  advantageous  in  the  bimanual  examination  in  some  cases,  to  cateli 
the  cervix  Avith  the  tenaculum  forceps  and  draAv  the  uterus  down-ward,  so 
that  the  examining  fingers  may  reach  higher  on  its  posterior  surface  (Fig. 
70).  This  is  useful  in  those  cases  where  the  uterus  lies  so  far  back  in  the  pel- 
vis that  it  is  difficult  to  reach.  After  making  the  vagino-abdominal  exam- 
ination in  the  usual  way,  the  tenaculum  may  then  be  introduced  by  touch  and 
the  cervix  caught  and  brought  down. 

Only  light  traction  should  be  made — not  enough  to  unduly  stretch  the 
sacro-uterine  ligaments,  which  might  lead  to  subsequent  trouble.  The  au- 
thor desires  to  protest  against  the  statement  made  by  some  authorities  to 
the  effect  that  the  normal  uterus  may  with  impunity  be  pulled  down  until  the 
cervix  appears  at  the  vaginal  opening,  or  may  without  harm  be  turned  into 
extreme  retroversion,  for  the  purpose  of  palpating  the  posterior  surface  or 
even  hooking  a  finger  in  the  rectum  over  the  fundus  and  palpating  the  an- 
terior surface.  The  uterus  is  usually  movable  in  all  directions,  but  the 
movements  here  mentioned  are  far  beyond  the  normal  range  and  can  be  ac- 
complished only  by  undue  stretching  of  the  structures  intended  to  prevent 
such  displacements. 

Of  course,  when  the  pelvic  structures  are  already  over-stretched  and  lax, 
as  in  cases  of  laceration  of  the  pelvic  floor  with  descent  of  the  uterus  or  in 
cases  of  movable  retrodisplacement,  these  extreme  maneuvers  may  be  carried 
out  without  further  damage,  and,  in  doubtful  cases,  Avith  great  advantage  in 
regard  to  accuracy  of  diagnosis.  In  a  patient  with  practically  normal  uterine 
supports,  however,  the  pulling  down  of  the  uterus  or  the  backAvard  displace- 
ment of  the  uterus  for  diagnostic  purposes  or  for  therapeutic  purposes  (as 
in  curetment  or  repair  of  cervix),  should  be  of  very  limited  extent.  It  is 
easy  to  over-stretch  the  uterine  supports  but  it  is  not  so  easy  to  restore  tone 
to  these  structures  so  that  they  will  again  hold  the  uterus  in  just  the  right 
way.  This  is  particularly  important  in  regard  to  the  postcervical  supports 
(sacro-uterine  ligaments  and  adjacent  tissues)  which  are  stretched  every 
time  the  cervix  is  pulled  doAvmvard.  When  these  are  once  over-stretched  and 
rendered  lax,  it  is  practically  impossible  to  keep  the  uterus  permanently  in 
proper  position  except  by  operation. 

Preferable  Position  for  Examiner 

For  the  vaginal  and  bimanual  examinations,  it  is  decidedly  advantageous 
for  the  examiner  to  stand  directly  in  front  of  the  vagi]ial  opening,  as  shoAvn 
in  Fig.  71.  This  is  especially  important  when  very  deep  pelvic  palpation  is 
necessary.  This  is  the  usual  position  Avhen  the  patient  is  examined  on  the 
table  with  footrests  so  that  the  lii])s  may  be  brought  entirely  to  tlie  end  of 
the  taljle. 


BIMANUAL    EXAMINATION  105 

When  a  patient  is  examined  in  bed,  hoAvever,  the  usual  directions  are  to 
pass  the  examining  arm  under  one  thigh.  This  puts  the  examining  arm  and 
liand  at  a  decided  disadvantage.  The  examiner  should  sit  so  that  the  ex- 
amining arm  passes  between  the  thig'hs  as  shown  in  Fig.  121.  This  puts  the 
arm  directly  in  front  of  the  genitals,  the  same  as  in  the  examination  on  the 
tal)le.  This  brings  the  arm  and  hand  in  the  most  advantageous  position  for 
accurate  palpation  deep  in  the  pelvis,  as  the  reader  can  easily  demonstrate 
to  his  own  satisfaction  by  giving  a  trial  to  each  method  in  some  difficult  case 
requiring  deep  palpation. 

Conditions  in  Different  Patients 

The  facility  Avith  Avhich  the  bimanual  examination  can  be  made  varies 
much  in  different  patients.  In  some,  the  fingers  on  entering  the  vagina  are 
checked  by  the  strong  contraction  of  the  muscles  of  the  pelvic  floor.  .  When 
such  is  the  ease,  turn  the  palmar  surface  of  the  examining  fingers  backward 
and  make  steady  pressui'c  against  the  posterior  vaginal  wall  and  the  contract- 
ing muscles.  This  gives  you  an  idea  of  the  strength  of  the  muscles  of  the 
pelvic  floor  and  soon,  under  the  pressure,  the  muscles  relax.  Another  trouble- 
some obstacle  to  deep  bimanual  examination  is  tension  of  the  abdominal  wall. 
The  methods  of  overcoming  this  have  already  been  explained. 

In  a  thin  patient,  with  a  large  vagina  and  a  relaxed  abdominal  wall, 
the  uterus  can  be  outlined  and  the  appendages  felt,  and  any  abnormal  mass, 
even  a  small  one,  can  be  satisfactorily  palpated. 

In  a  stout  patient,  Avith  a  thick  layer  of  fat  over  the  abdomen,  the  ordi- 
nary bimanual  examination  is  often  unsatisfactory,  particularly  if  there  is 
inflammatory  trouble  Avith  tension  of  the  abdominal  Avail.  In  such  a  case, 
a  mass  of  considerable  size,  if  situated  high  in  the  pelvis,  may  be  missed 
entirely.  The  only  Avay  to  determine  exactly  the  pehdc  contents  in  such  a 
case  is  to  make  an  examination  under  anesthesia.  Such  an  examination 
should  be  made  in  those  cases  where  the  symptoms  are  urgent  enough  to 
make  an  innnediate  accurate  diagnosis  necessary. 

Get  Intestines  Out  of  the  Way 

In  some  cases,  particularly  when  there  is  considerable  tympanites,  dis- 
tended coils  of  intestine  interfere  with  the  bimanual  palpation  of  the  pelvic 
structures. 

To  overcome  this  difficulty,  elevate  the  patient's  hips  into  the  Trendelen- 
burg posture.  Then  Avork  the  intestines  out  of  the  pelvis  and  hold  them  out 
as  the  hips  are  sloAAly  loAvered  into  a  more  comfortable  position.  Leave  the 
hips  rather  high,  as  high. as  the  patient  Avill  stand  without  discomfort,  and 
direct  her  to  keep  all  the  nuiscles  loose  and  breathe  quietly,  so  as  not  to  force 
the  intestinal  coils  back  into  the  pelvis.  The  regular  bimanual  palpation 
may  then  be  carried  out,  undisturbed  by  the  troublesome  intestinal  coils. 


106  GYNECOLOGIC    EXAillNATION    METHODS 

This  is  a  very  convenient  maneuver  also  for  getting  a  pedicnlated  tumor 
out  of  the  pelvis,  that  its  pedicle  and  point  of  origin  may  be  accurately  de- 
termined by  bimanual  palpation. 

In  case  the  table  is  not  arranged  for  the  convenient  elevation  of  the  hips, 
the  hips  may  be  elevated  by  means  of  pillows  or  the  patient  may  be  placed  in 
the  knee-chest  posture  for  a  few  moments.  With  the  clothing  well  loosened 
and  the  correct  knee-chest  posture  assumed,  the  distended  intestinal  coils 
fall  out  of  the  pelvis  better  than  in  the  Trendelenburg  posture,  but  in  the 
exertion  of  assuming  the  dorsal  posture  again  they  are  likel}^  to  be  partiallj- 
forced  back.  Avoid  this  as  much  as  possible  by  directing  the  patient  to  keep 
the  upper  part  of  the  body  on  the  table  (not  to  raise  it,  as  in  partly  sitting 
up)  and  to  keep  the  abdominal  muscles  loose.  Also  place  a  thick  pillow  under 
the  hips,  as  the  dorsal  posture  is  assumed.  An  additional  expedient  is  to  put 
a  speculum  in  the  vagina  and  in  the  rectum  while  the  patient  is  in  the  knee- 
chest  posture.  The  vagina  and  rectum  then  balloon  with  air,  forcing  the 
intestinal  coils  out  of  the  pelvis.  The  specula  are  then  removed  and  the 
openings  close,  retaining  the  air  which  helps  to  keep  the  intestinal  coils  out 
of  the  pelvis  in  the  subsequent  movements. 

Diminish  Tenderness 

In  many  patients  satisfactory  pelvic  exploration  is  prevented  by  tender- 
ness, particularly  in  that  large  class  of  cases  in  which  pelvic  inflammation  is 
a  primary  or  complicating  lesion.  In  some  of  these  cases  the  sjanptoms  are 
so  urgent  that  an  examination  under  anesthesia  at  once  is  advisable.  In  most 
of  the  cases,  however,  the  symptoms  are  not  so  threatening  as  to  necessitate 
immediate  examination  under  anesthesia.  The  patient  has  come  for  a  diag- 
nosis but  an  accurate  diagnosis  can  not  be  made  because  of  the  tenderness 
which  prevents  deep  palpation.  What  shall  the  examiner  do  under  these  cir- 
cumstances? There  are  two  measures  which  are  useful  in  diminishing  the 
tenderness  and  abdominal  tension. 

1.  Administration  of  a  sedative.  The  patient  may  be  given  14  gr.  of 
codeine  phosphate  hypodermatically,  or  %  gr.  or  14  gr.  of  morphia,  and  ex- 
amined again  after  half  an  hour. 

If  thought  preferable,  an  appointment  may  be  made  for  the  next  day 
and  an  order  given  for  the  sedative  to  be  taken  by  mouth  one  hour  before 
your  visit.  In  the  meantime  the  patient  is  kept  quiet  in  bed  and  the  bowels 
well  opened.  It  is  well  to  have  an  enema  given  half  an  hour  before  ex- 
amination. 

2.  Treatment  for  the  inflammation.  The  patient  is  kept  in  bed,  the 
bowels  Avell  opened,  hot  vaginal  douches  given  and  the  regular  treatment 
for  acute  or  subacute  pelvic  inflammation  carried  out.  This  treatment  con- 
tinued for  a  few  days  or  a  Aveek  will  do  much  toward  diminishing  the  ten- 
derness, so  that  a  thorough  pelvic  examination  may  lie  made. 


RECTO-ABDOMINAL   PALPATION  107 

RECTO-ABDOMINAL  PALPATION 

111  many  cases  it  is  of  decided  advantage  to  follow  the  vagino-abdominal 
examination  by  a  recto-abdominal  examination.  In  this  form  of  bimanual 
examination,  the  index-finger,  gloved  and  lubricated,  is  introduced  into  the 
rectum  and  passed  upward  between  the  sacro-uterine  ligaments  as  far  as 
possible  up  the  posterior  surface  of  the  uterus.  With  the  fingers  of  the 
other  hand  pressing  down  the  organs  from  above,  all  the  structures  within 
reach  are  palpated  with  the  palmar  surface  of  the  rectal  finger  (Fig.  101). 

Disadvantages 

Ordinarily,  palpation  of  the  pelvic  structures  may  be  carried  out  much 
more  thoroughly  by  vagino-abdominal  examination  than  by  recto-abdominal 
examination.  Without  anesthesia  but  one  finger  can  be  used  in  the  rectum 
and  this  finger  lies  at  a  considerable  distance  from  the  uterus  and  adnexa, 
unless  carried  very  high.  It  can  not  usually  be  carried  very  high  on  ac- 
count of  the  encircling  sphincter  and  pelvic  floor,  except  by  the  use  of  such 
force  as  to  cause  pain  and  resistance.  In  some  cases  where  the  pelvic  floor 
is  lax,  the  examining  hand  may  easily  carry  the  perianal  structures  some 
distance  into  the  pelvis,  thus  allowing  the  examining  finger  to  pass  high  up 
back  of  the  uterus  and  permitting  accurate  bimanual  palpation  of  the  ad- 
nexa. The  facility  with  which  the  organs  may  be  felt  is  increased  by  catch- 
ing the  cervix  with  a  tenaculum  forceps  and  bringing  the  uterus  somewhat 
lower.  In  all  but  exceptional  eases,  however,  accurate  examination  of  the 
pelvic  contents  by  recto-abdominal  palpation  is  practicable  only  under  anes- 
thesia. However,  such  palpation  as  can  be  carried  out  without  anesthesia 
gives  information  of  value  in  some  cases,  as  indicated  in  the  following 
paragraphs. 

When  Useful 

It  is  well  to  employ  digital  examination  per  rectum,  or  conjoined  (bi- 
manual) recto-abdominal  palpation,  in  the  following  cases: 

Mass  in  Cul-de-sac.  Rectal  palpation  is  useful  when  there  is  a  mass  of 
inflammatory  exudate  or  a  tumor  Ioav  in  the  peritoneal  cul-de-sac  back  of  the 
uterus.  In  the  case  of  an  inflammatory  mass  in  that  situation,  fluctuation 
may  be  in  some  cases  detected  while  it  is  not  yet  appreciable  by  vaginal 
examination. 

Malignant  Infiltration.  In  malignant  disease  of  the  cervix  extending 
out  into  the  parametrium,  rectal  palpation  Avill  in  some  cases  give  additional 
information  as  to  the  extent  of  the  infiltration  and  the  mobility  or  fixation 
of  the  uterus. 

Rectal  Disease.  When  a  patient  gives  symptoms  pointing  to  rectal  dis- 
ease, the  rectum  should  of  course  be  examined  by  palpation  and  also  by  in- 


108  GYNECOLOGIC    EXAMINATION    METHODS 

sijeetion  through  i-ectal  speeuluni  if  necessary  to  determine  the  exact  condition. 

Obscure  Cases.  In  eases  where  the  other  methods  do  not  sliow  lesions 
sufficient  to  account  fov  the  symptoms,  a  rectal  examination  should  be  made 
to  determine  if  there  is  any  rectal  or  perirectal  disease  that  might  account 
for  the  pelvic  pain  and  distress. 

Occasionally  in  a  Virgin.  The  information  concerning-  the  uterus  and 
adnexa  thus  obtained  is  usually  very  indefinite,  as  explained  below.  In  such 
examination  the  landmark  is  the  cervix  uteri,  which  may  be  easily  felt 
through  the  rectal  wall.  Notice  if  there  is  a  distinct  mass  back  of  the  cervix 
(inflammatory  mass,  tumor,  fundus  uteri  in  retrodisplacement)  or  a  point  of 
special  tenderness  anywhere  in  the  lower  part  of  the  pelvis. 

BIMANUAL  EXAMINATION  OF  A  VIRGIN 

As  previously  explained,  local  examination  in  the  case  of  a  virgin  is  to 
))e  avoided  if  possible.  When  it  is  necessary  to  make  an  intrapelvic  exam- 
ination, what  method  should  be  used? 

The  direction  has  been  given,  in  A^arious  works,  to  examine  virgins  by  the 
rectum  when  it  is  necessary  to  determine  the  condition  of  the  uterus  or  ad- 
nexa, in  order  to  avoid  stretching  the  hymen.  In  a  virgin  those  conditions 
which  militate  against  a  satisfactory  palpation  of  the  uterus  and  adnexa  by 
recto-abdominal  examination,  are  at  their  height.  Usually  after  such  an  ex- 
amination without  anesthesia  the  examiner  knows  but  little  more  concerning 
the  uterus  and  adnexa  than  he  did  before  the  examination.  Of  course  if  there 
is  a  good  sized  mass  low  in  the  pelvis  or  a  particularly  tender  area,  its  pres- 
ence is  determined.  But  the  information  is  usually  too  indefinite  for  an  exact 
diagnosis.  Such  an  examination  does  very  well  however,  to  ''break  the  ice" 
so  to  speak,  and  it  may  be  explained  then  that  the  conditions  are  such  that 
a  vaginal  examination  is  advisable.  In  some  cases  the  recto-abdominal  ex- 
amination is  very  satisfactory,  the  required  information  being  obtained  with 
fair  accuracy. 

Ill  the  rectal  palpation,  the  cervix  uteri  can  be  felt  through  the  i-ectal 
Avall.  If  there  is  no  mass  back  of  the  cervix  (inflammatory  mass  or  tumor  or 
fundus  uteri  deep  in  cul-de-sac)  and  no  area  of  particular  tenderness  in  the 
pelvis,  it  may  be  advisable  to  postpone  further  local  examination  and  try 
general  therapeutic  measures  for  several  weeks  or  months. 

Usually,  however,  when  the  symptoms  are  severe  enough  to  Avarrant  any 
local  examination,  they  are  severe  enough  to  Avarrant  a  recto-abdominal  ex- 
amination under  anesthesia,  or  a  stretching  of  the  hymen  sufficiently  to 
admit  one  finger,  so  that  the  regular  A'aginal  and  vaginal-abdominal  examina- 
tion may  be  m^de.  The  condition  of  the  uterus  and  the  adnexa  may  be  much 
more  definitely  determined  in  this  Avay  than  by  rectal  i^alpation. 

In  a  large  proportion  of  virgins,  even  the  regular  vagino-abdominal  pal- 


RECT0-VAG1N0-A15D0MINAL    I'ALI'ATION 


109 


patioii  does  not  permit  aeeurate  outlining  of  the  uterus  or  of  adnexal  masses. 
Consequently,  in  the  case  of  a  virgin  Avhere  there  is  serious  pelvic  trouble 
necessitating  an  accurate  palpation  of  the  pelvic  contents,  an  examination 
under  anesthesia  is  usually  required.  In  cases  where  the  necessity  of  a 
thorough  pelvic  examination  is  apparent  from  the  first,  it  is  prefei-able,  in  a 
girl  or  a  young  unmarried  Moman,  to  at  once  examine  the  patient  under  an 
anesthetic.  This  eliminates  the  mental  shock  of  the  procedure  and  at  the 
same  time  permits  a  thorough  exploration.  It  is  well  to  employ  recto-ab- 
dominal palpation  first  and  then,  if  necessary,  vagino-abdominal  palpation. 
In  addition,  any  operative  measure  required  for  diagnostic  or  therapeutic 
purposes  may  be  carried  out,  for  example,  dilatation  and  cui-etment  of  uterus 
or  removal  of  hemorrhoids. 

RECTO-VAGINO-ABDOMINAL  PALPATION 

In  exceptional  cases  Avhen  making  the  recto-abdominal  examination,  it  is 
advantageous  to  introduce  the  thumb  into  the  vagina  in  order  to  grasp  the 


Fig.    85.      Method    of    palpating   tlie    coccyx.      The    hand    shonld    be    gloved.       (Hirst — Diseases    of    IVometi.) 


lower  part  of  a  mass  between  the  finger  in  the  rectum  and  the  thumb  in  the 
upper  part  of  the  vaginal  canal,  the  structure  being  pushed  down  within 
reach  by  the  abdominal  hand  (recto-vagino-abdominal  palpation).  Where  a 
mass  is  low  enough  to  be  grasped  in  this  Avay,  its  outline  and  consistency  can 
be  very  accurately  determined.  It  is  only  in  the  cases  of  large  vaginal  open- 
ing and  relaxed  floor  that  this  method  is  applicable,  and  to  be  of  mucli 
service  anesthesia  is  usually  required.  Occasionally,  however,  it  is  useful  in 
the  ordinary  examination. 


110  GYNECOLOGIC    EXAMINATION    METHODS 

The  author  recalls  in  particular  one  puzzling  case,  that  was  referred  to 
him  for  differential  diagnosis,  in  which  this  maneuver  was  of  much  assist- 
ance. The  patient  presented  a  mass  of  moderate  size,  pretty  well  filling  the 
pelvis.  The  mass  contained  fluid,  the  cervix  was  somewhat  softened  and  the 
uterine  body  could  not  be  definitely  located.  The  differentiation  was  be- 
tween an  enlarged  uterus  containing  fluid  (normal  or  abnormal  pregnancy) 
and  some  other  fluid  mass  (cystic  fibroid,  extrauterine  pregnancy,  hydrosal- 
pinx, ovarian  or  parovarian  cyst).  The  history  was  uncertain  and  the  find- 
ings in  the  ordinary  examination  were  not  positive.  The  crucial  point  was  to 
identify  the  body  of  the  uterus.  Was  this  large  mass  the  body  of  the  uterus 
enlarged  (pregnancy)  or  was  the  body  of  the  uterus  of  practically  normal  size 
and  located  somewhere  in  the  mass? 

Sounding  of  the  uterine  canal  was  not  permissible  until  pregnancy  could 
be  excluded.  The  lower  posterior  part  of  the  large  mass  presented  a  small 
firm  portion,  Avhich  might  be  the  normal-sized  body  of  the  uterus  displaced  or 
simply  a  firm  portion  of  an  enlarged  uterus.  The  firm  area  was  so  covered 
over  and  surrounded  by  the  mass  that  the  author  could  not  make  satisfactory 
bimanual  palpation  of  it,  neither  could  he  definitely  outline  it  through  a  suffi- 
cient extent  by  either  vaginal  or  rectal  palpation.  Finally  he  tried  to  grasp 
this  firm  portion  of  the  mass  between  the  finger  in  the  rectum  and  the  thumb 
in  the  vagina.  As  the  vaginal  opening  and  pelvic  floor  were  lax,  he  could 
carry  the  thumb  to  the  top  of  the  vagina  without  much  discomfort  to  the 
patient,  and  by  crowding  the  mass  down  with  the  abdominal  hand,  was  able 
to  grasp  the  firm  portion  between  the  finger  and  the  thumb  of  the  left  hand 
and  separate  it  from  the  fluid  mass  sufficiently  to  trace  its  outline  and  get  the 
consistency  throughout.  It  was  of  about  the  size,  shape  and  consistency  of  tlie 
normal  uterus,  and  by  working  the  finger  and  thumb  toward  each  other  above 
this  firm  part,  he  could  demonstrate  that  the  fluid  portion  of  the,  mass  had 
a  separate  wall.  He  now  felt  safe  in  introducing  the  sound,  Avhich  confirmed 
the  palpation  findings.  This  firm  area  was  the  displaced  body  of  the  uterus, 
otherwise  practically  normal,  and  the  surrounding  fiuid  mass  Avas  a  separate 
affair,  an  ovarian  or  parovarian  cyst. 

A  modification  of  this  method  is  to  introduce  the  middle  finger  into  the 
rectum  and  the  index  finger  into  the  vagina  and  palpate  the  structures  be- 
tween the  fingers,  as  the  uterus  is  pushed  down  from  above.  This  particular 
method  of  recto-vagino-abdominal  palpation  has  been  found  useful  in  deter- 
mining the  extent  of  involvement  of  the  parametrium  in  cases  of  carcinoma  of 
the  cervix  uteri. 

PALPATION  OF  COCCYX 

In  cases  of  persistent  pelvic  pain  where  no  sufficient  cause  is  found  about 
the  uterus  or  adnexa,  the  coccyx  should  be  palpated.  This  small  bone  at  the 
tip  of  the  sacrum  is  not  infrequently  the  site  of  neuralgia  or  rheumatism  (af- 
fecting the  joints  or  adjacent  muscles)   or  a  chronic  inflammation  resulting 


INSTRUMENTAL    EXAMINATION  111 

from  an  injury  sustained  months  or  years  before.  These  injuries  usually  can 
he  traced  to  childbirth  tliough  occasionally  such  a  condition  will  result  from 
a  fall  or  bloAv.  In  rare  cases,  neuralgia  or  rheumatism  or  inflammation  may 
become  manifest  here  without  previous  injury.  Tenderness  of  the  Coccyx  or 
a  mass  about  any  portion  of  it  or  a  deformity,  may  be  easily  determined  by  an 
examination  with  the  index  finger  (gloved)  in  the  rectum  and  the  thumb  over 
the  coccyx  (Fig.  85).  The  examination  is  most  conveniently  made  Avith  the 
patient  lying  on  her  side.  In  this  Avay  the  coccyx  may  be  accurately  outlined 
and  any  deviation  from  the  normal  determined.  In  some  cases  the  coccyx 
appears  to  be  normal  until  an  attempt  is  made  to  move  it,  when  there  is  severe 
pain,  indicating  trouble  in  the  joint  or  about  the  fasciae  or  muscles. 

INSTRUMENTAL  EXAMINATION 

This  term  includes  those  manipulations  in  which  it  is  necessary  to  use 
instruments.     Coming  under  this  classification  are  the  following: 

Inspection  of  Vagina  and  Cervix  through  the  Speculum  (Speculum 

Examination) . 
Excision  of  Tissue  from  Cervix  for  JMicroscopic  Examination. 
Exploration  of  Interior  of  Uterus  Avith  the  Sound. 
Exploration  of  Interior  of  Uterus  Avith  the  Curet. 

SPECULUM  EXAMINATION 

By  means  of  certain  instruments  the  A^aginal  Avails  may  be  spread  apart 
so  that  those  Avails  and  the  cerAdx  uteri  may  be  seen.  Information  of  much 
value  in  some  cases  may  be  obtained  in  this  Avay. 

Instruments  for  Regular  Speculum  Examination 

The  instruments  needed  for  this  examination  are  shoAvn  in  Fig.  86.  They 
are  as  foUoAvs: 

A  Speculum  for  separating  the  A'aginal  Avails; 

A  long  Dressing  Forceps  for  sponging  out  the  vagina,  usually  called 

"Uterine  Dressing  Forceps;" 
A  Tenaculum  Forceps,  or  "Volsellum,"  for  catching  the  cervix  and 

bringing  it  better  into  a'Icav. 
A  Specimen  Scissors. 
Vaginal  Speculum.  The  bivalve  speculum  (Fig.  86,  a)  is  the  kind  most 
frequently  used  in  ordinary  office  Avork.  It  consists  of  Iavo  blades,  Avhich  are 
introduced  closed  and  then  opened  by  a  mechanism  at  the  handle.  The  vaginal 
Avails  are  thus  held  apart  (Fig.  87)  and  a  very  good  aqcav  of  the  Avails  and  cer- 
vix may  be  obtained.  The  bivalve  speculum  is  convenient  and  gives  good  ex- 
posure of  the  cervix  in  most  cases. 

There  are  many  different  modifications  of  the  blades  and  also   of  the 


112 


GYXECOLOGIC    KXAMIXATJOX    .METHODS 


mechanism  for  separating  the  bhides.  The  most  satisfactory  form  that  the 
author  has  found  is  shown  in  the  illustration.  It  is  called  the  Graves  specu- 
lum and  has  the  advantage  that  it  can  he  easily  and  quickly  transformed  into 
a  fairly  satisfactory  Sims'  speculum,  -which  is  a  decided  convenience  in  office 
work.  Three  sizes  are  useful — small  (virgin),  medium  and  large.  The  cervix 
is  easier  exposed  in  most  cases  if  the  anterior  blade  of  the  speculum  is  some- 
what shorter  than  the  posterior. 

Some  specula  are  made  A\'ith  three  blades,  instead  of  two,  constituting  a 
ti'ivah'e   speculum.      They   are   made    on  the   same    general  principles    as   the 


Fig.  86.  Instruments  for  the  regular  speculum  exsmination.  a.  Bivalve  Speculum,  of  which 
it  is  well  to  have  three  sizes — large,  medium,  and  small.  b.  Dressing  Forceps  for  swabbing  out 
vagina.  c.  Tenaculum  forceps  for  catching  cervix  to  bring  it  well  into  view.  d.  Specimen  Scissors, 
a   small    strong   hawk-bill    scissors    for    clipping    small    specimens    from    the    cervix    in    suspicious    cases. 


bivalve  but  the  mechanism  is  more  complicated  and.  usually,  Avithout  corre- 
sponding benefit. 

The  bivalve  speculum  is  used  A\-ith  the  patient  in  the  dorsal  posture  (Fig. 
39).  For  sterilization  of  specula  and  other  instruments,  see  Preparations  for 
Examination,  at  the  end  of  this  chapter. 

The  Uterine  Dressing'  Forceps  (Fig.  '^'o.  l)i  is  a  long  strong  forceps  for 
sponging  out  the  vagina  and  for  making  vaginal  applications.  It  may  be 
straight  or  curved  as  preferred.  The  author  finds  the  forceps  \\\t\\  a  straight 
shank  and  a  slight  curA-e  near  the  end  more  convenient  than  the  much  curved 
instrument.     A  vaginal  depressor  for  pushing  the  A'agiual  \\-a\\  out  of  the  way 


IXSTRU MENTAL    KXAMIXATIOX 


113 


is  usually  mentioned  in  an  examining  set.  but  it  is  generally  not  necessary,  as 
the  vaginal  wall  may  be  pushed  aside  sufficiently  \vith  the  dressing  forceps. 

The  Uterine  Tenaculum  Forceps  is  needed  for  catching  the  cervix  and 
liringing  all  parts  of  it  into  view.  It  should  be  light  but  strong,  especially 
about  the  lock,  where  it  is  likely  to  work  loose  (Fig.  86,  cj. 


•"♦Jf^S*-^***^ 


Fig.    87.      Bivalve    Speculum    in    place.       Sectional    view,    showing    relations    of    speculum    and    exposure    of 
the   cervix   and   vaginal   vault   by   opening  the   blades. 


The  Specimen  Scissors  are  for  clipping  out  a  small  piece  of  tissue  from  the 
cervix,  in  cases  presenting  an  appearance  suspicious  of  malignant  disease. 
The  one  shown  in  Fig.  86,  d,  the  author  has  found  very  convenient  and  satis- 
factory. It  presents  at  the  end  a  small  sharp  "hawk-bill"  which  cuts  through 
the  firmest  tissue,  clipping  out  a  small  piece  with  but  little  pain  or  bleeding. 


114  GYNECOLOGIC    EXAMIXATIOX    ^[ETHODS 

The  aiitlior  apprupriated  it  t'roiii  the  tliroat  specialist's  ariiiaiueiitariiim,  where 
it  is  catalogued  as  the  ]\Iiles  tonsil  iDitnch.  Another  convenient  instrument  for 
this  purpose  is  the  Gaylor  specimen  scissors  shown  in  Fig.  88. 

Steps  in  the  Regular  Speculum  Examination 

Introducing-  the  Speculum.  The  blades  of  the  speculum  are  closed  and 
the  outer  surfaces  lubricated  and  the  speculum  held  iu  the  right  hand,  while 
with  the  other  hand  the  labia  are  separated  and  the  perineum  depressed  some- 
what with  one  finger  (Fig.  89).    The  speculum  is  then  introduced  and  carried 

all  the  Avav  to  the  upper  end  of  the  vagina  without  being  opened.  In  most 
cases  the  speculum  passes  the  vaginal  entrance  most  easily  when  held  with  its 
width  almost  vertical,  the  edge  being  held  just  far  enough  to  one  side  to 
miss  the  urethra  iFig.  90).  AVhen  well  within  the  vagina,  it  is  ttirned  trans- 
verseh'  and  carried  in  as  far  as  it  will  go  iFis".  91).  ,-i>' 


Fig.   88.      Gaylor's  Scissors  for  the  removal  of  pieces  of  cervical  tissue  for  microscopic  examination. 

Care  is  necessary  that  painful  pressure  ])e  not  made  on  the  urethra  oi' 
other  structures  beneath  the  pubic  arch.  Eemember  that  when  more  room  is 
required,  the  pressure  must  always  be  directed  against  the  perineum,  Avhich 
will  gradually  yield. 

Atiother  common  mistake  with  the  inexperienced  is  to  open  the  blades  too 
soon,  before  the  speculum  has  been  introduced  all  the  way.  The  blades  are  not 
in  far  enough  to  satisfactorily  expose  the  cervix  and  in  closing  them  again 
for  further  introduction,  pain  is  likely  to  be  produced  by  pinching  the  vaginal 
wall. 

Exposing  the  Cervix.  After  the  blades  have  been  introduced  well  up  to 
the  top  of  the  A'agina,  they  are  opened  and  the  cervix  and  vaginal  walls  exposed 
fFig.  87).  By  turning  the  speculum  in  various  directions,  all  parts  of  the  cer- 
vix and  upper  end  of  the  A'agina  may  be  seen.    If  the  cervix  does  not  come  Avell 


INSTRUMENTAL   EXAMINATION 


115 


into  view  it  may  be  caught  with  a  tenaculum  forceps  and  brought  downward 
somewhat  and  turned  from  side  to  side,  exposing  all  portioiis  of  it  and  of  the 
vaginal  vault. 


Fig.  89. 


Introducing    the    bivalve    speculum.      First    step — depressing    the    perineum    to    give    room    for    the 
speculum  to  be  introduced. 


Fig.     90.       Introducing    speculum.       It    has    been         Fig.    91.      The   speculum   carried  all   the   way    in   and 
carried    part    way    in.      Notice    the    oblique    position,  turned   into   position   for    opening, 

which  prevents  painful  pressure  on  the   urethra. 


116  GYNECOLOGIC    EXAMINATION    METHODS 

Cleansing"  the  Vagina.  If  there  is  secretion  obseiiring  any  part  of  the  vag- 
inal wall  or  cervix,  wipe  it  away  with  cotton  held  in  the  dressing  forceps  and 
dipped  in  an  antiseptic  solution. 

Exposing  Lower  Portion  of  Vaginal  Walls.  To  inspect  the  middle  and 
lower  portions  of  the  vaginal  Avails,  turn  the  speculum  so  as  to  bring  the  va- 
rious portions  of  the  walls  opposite  the  opening  between  the  blades.  Another 
way  is  to  inspect  the  various  portions  of  the  Avails  just  beyond  the  end  of  the 
speculum,  as  it  is  AvithdraAvn.  Specula  Avith  skeleton  blades  are  made,  but  they 
are  not  necessary  and  ordinarily  they  are  likely  to  prove  unsatisfactory  in  a 
good  many  cases  because  of  the  prolapsing  of  the  redundant  vaginal  Avails 
through  the  large  openings. 

Information  Obtained  in  the  Speculum  Examination 

The  information  sought  in  the  speculum  examination  is  obtained  by  in- 
spection of  the  folloAving  structures: 

Vaginal  Walls — Color,  Discharge,  Redundancy; 

Cervix  Uteri — Position,  Color,  Size  and  Shape,  Lacerations,  Deviation 
of  Axis,  Eversion,  Erosion,  Hypertrophy,  Cystic  Change,  Ulcer; 
External  Os — Size  and  Shape,  Color  of  Edges,  Discharge,  Polypi. 

Vaginal  Walls.  Are  the  Avails  of  normal  color  or  is  there  congestion?  If 
congestion,  is  it  active  or  passive?  If  the  Avails  are  bright  red,  that  means 
actiA^e  or  arterial  congestion  and  is  due  to  inflammation  or  irritation.  If  the 
Avails  haA^e  a  bluish  tinge,  that  means  passiA^e  or  A^enous  congestion  and  indi- 
cates either  pregnancy  or  some  interference  Avith  the  circulation,  as  by  a  pel- 
A^c  tumor  or  exudate  or  by  failure  in  compensation  in  heart  disease. 

If  there  is  discharge,  determine  Avhether  it  originates  in  the  A^agina  or  in 
the  uterus.  If  the  vaginal  Avails  are  lax  and  redundant,  they  tend  to  collapse 
about  the  speculum. 

Cervix  Uteri.  Is  the  cervix  in  Ioav  position,  so  that  it  iis  easily  exposed 
Avhen  the  speculum  is  in  but  a  short  distance,  or  is  it  higher  than  normal,  so 
that  it  can  not  be  well  exposed  with  the  speculum  of  ordinary  length  ?  Is  the 
color  normal  or  is  there  congestion,  either  active  or  passiA^e?  Here,  as  in  the 
vaginal  Avail,  active  congestion  means  inflammation  or  irritation  and  passive 
congestion  indicates  either  pregnancy  or  obstruction  of  the  circulation.  A 
bright  red  area  extending  a  considerable  distance  out  from  the  os,  is  usually 
due  to  the  peculiar  condition  called  "erosion." 

In  regard  to  the  size  and  shape,  inspection  may  shoAv  the  cerA^ix  to  be: 
Normal. 
Long  Conical. 

Lacerated,  but  largely  united  again. 
Lacerated  and  not  united,  but  Avithout  complications. 
Lacerated  and  everted,  eroded,  hypertrophied,  or  Avith  cystic  change 
or  Avith  a  genuine  ulcer. 


INSTRUMENTAI.   EXAMINATION 


117 


Fig.    92.      A,    Schultze    Tampon;    B,    Ordinary    Tampon. 


Fig.     93.       Suction     Bulli    and    Tube     for    the     aspiration     of     Cervical     Secretion. 


Fig.   94.     A.   Sims'    Speculum,   two   blades   of  different  sizes   attached   to  one   handle;     B.    Flange   attached   to 
one  blade  to   hold  back  buttocks;   C.   Graves'    IJivalve   Speculum  changed   to   the   Sims   type. 


118  GYNECOLOGIC   EXAMINATION    METHODS 

Is  the  axis  of  the  cervix  directed  across  the  vagina,  as  it  should  be  nor- 
mally, or  ALONG  the  vagina,  as  in  retrodisplacement  of  uterus  or  anteflexion  of 
cervix  ? 

External  Os.  The  size  and  shape  show  whether  or  not,  there  has  been 
laceration  and  consequently  are  of  considerable  medico-legal  importance  in 
certain  cases,  because  furnishing  strong  evidence  for  or  against  a  previous 
childbirth.  The  color  of  the  edges  show  whether  they  are  normal  or  the  seat 
of  inflammation  or  erosion. 

The  discharge  may  be  of  any  of  the  varieties  previously  described.  There 
is  normally  a  clear  sticky  tenacious  mucus  in  the  cervix  and  about  the  external 
OS.  The  first  effect  of  inflammation  and  irritation  is  to  make  this  more 
abundant  and  later  it  becomes  mixed  with  pus.  As  long  as  the  cervical  inflam- 
mation is  a  prominent  part  of  the  process,  the  tenacious,  stringy  quality  will 
be  a  prominent  feature  of  the  discharge.  If  there  is  the  least  suspicion  of 
gonorrhea,  make  a  spread  of  the  discharge  for  microscopic  examination.  In 
exceptional  cases  it  may  be  advisable  to  use  a  tampon  to  determine  the 
amount  of  discharge  and  whether  it  comes  from  the  uterus  or  vaginal  Avail. 
A  Schultze  tampon  (Fig.  92,  a)  or  an  ordinary  tampon  (Fig.  92,  b)  is  intro- 
duced. The  patient  is  directed  to  report  at  the  office  after  a  specified  number 
of  hours,  Avhen  the- tampon  is  carefully  remoA^ed  and  examined  as  to  the  amount 
and  location  of  discharge  upon  it.  With  the  suction  bulb  and  tube  (Fig.  93) 
discharge  lying  in  the  uterine  canal  may  be  AvithdraAvn  for  diagnostic  or  thera- 
peutic purpose.  Occasionally  a  small  polypus  Avill  be  seen  presenting  at  the 
external  os  or  hanging  by  a  pedicle. 

Difficulties  in  the  Speculum  Examination 

Poor  Lig'ht.  If  the  light  is  so  poor  that  the  cervix  and  upper  portion  of 
the  vagina  can  not  be  seen,  the  ordinary  head  mirror,  used  in  throat  work,  is 
of  much  assistance.  At  night,  in  emergency  examinations  and  treatment,  the 
light  from  a  lamp  may,  Avith  the  head  mirror,  be  throAvn  into  the  vagina  and  the 
landmarks  easily  seen. 

Painful  Abrasions.  If  there  are  painful  abrasions  or  fissures  about  the 
vaginal  orifice  Avhich  interfere  Avith  the  examination,  the  sensitiveness  may  be 
diminished  by  the  application  of  a  small  piece  of  absorbent  cotton  soaked  in  a 
10%  cocaine  solution.  Leave  this  in  place  for  three  to  five  minutes,  then  re- 
move it  and  proceed  Avith  the  examination. 

Redundant  Vaginal  Walls.  When  the  vaginal  Avails  are  very  lax  and 
redundant,  as  sometimes  occurs  because  of  subinvolution  f olloAving  lab&r,  they 
collapse  about  the  speculum  in  such  a  Avay  as  to  hide  the  cervix.  This  diffi- 
culty may  in  some  cases  be  overcome  by  using  a  longer  speculum.  When  this 
does  not  expose  the  cervix  satisfactorily,  put  the  patient  in  Sims'  posture  and 
use  the  Sims  speculum. 


INSTRUMENTAL   EXAMINATION  119 

Examination  with  Cylindrical  Speculum 

The  cylindrical  speculum  consists  simply  of  a  tube  with  the  outer  end 
flaring  and  the  inner  end  cut  obliquely.  It  may  be  made  of  metal  or  hard 
rubber  or  glass.  The  cylindrical  speculum  is  useful  in  certain  forms  of  treat- 
ment, particularly  when  it  is  desired  to  apply  to  the  cervix  medicines  from 
which  the  vaginal  walls  should  be  protected,  but  it  is  not  much  used  in  ex- 
amination work. 

When  in  the  examination  of  a  girl  it  is  necessary  to  inspect  the  cervix, 
this  may  be  accomplished  without  disturbing  the  hymen  by  placing  the  patient 
in  the  knee-chest  posture  and  using  one  of  Kelly's  cystoscopic  tubes.  This  is 
simply  a  small  cylindrical  speculum  and,  with  the  patient  in  the  knee-chest 
posture,  when  the  tube  is  introduced  the  vagina  balloons  out  to  some  extent 
with  air.  Then  by  means  of  a  light  reflected  from  a  head  mirror,  the  cervix 
and  vaginal  walls  may  be  inspected  and  if  necessary  treated.  Such  an  ex- 
amination, however,  is  seldom  required,  In  the  virgin,  a  local  examination 
should  not  be  made  except  for  urgent  symptoms,  and  in  cases  with  urgent 
symptoms  the  requirement  is  usually  for  a  thorough  bimanual  examination 
under  anesthesia,  rather  than  for  a  speculum  examination. 

Examination  with  the  Sims  Speculum    . 

The  Sims  speculum  is  a  perineal  retractor  and  for  use  requires  the  patient 
to  be  put  in  the  Sims  posture.  Like  any  other  retractor,  it  must  be  held  in 
place  either  by  an  assistant  or  by  a  mechanism  (speculum  holder),  of  which 
there  are  several  varieties. 

The  Sims  speculum  consists  of  a  blade,  somcAvhat  resembling  a  duck's 
bill,  and  a  handle.  As  usually  made  two  blades  are  placed  on  one  handle,  a 
large  blade  at  one  end  and  a  small  blade  at  the  other.  (Fig.  94,  a).  A  further 
improvement  is  a  flange  near  the  larger  blade  (Fig.  94,  b).  This  flange  holds 
the  fleshy  part  of  the  right  buttock  up  out  of  the  way.  The  Graves  bivalve  specu- 
lum, mentioned  above,  is  easily  and  quickly  changed  into  a  satisfactory  Sims 
speculum  (Fig.  94,  c),  so  it  is  not  usually  necessary  to  get  a  special  Sims 
speculum. 

The  Sims  Posture.  The  principal  points  about  the  Sims  posture,  called  also 
"left  lateral  posture"  and  the  "semiprone  posture,"  are  as  follows: 

1.  All  constriction  must  be  removed  from  around  the  waist. 

2.  The  patient  lies  on  her  left  side,  with  left  arm  and  hand  behind  her 
and  the  front  of  the  chest  turned  toward  the  table  as  far  as  possible  Avithout 
discomfort.  When  in  proper  position,  the  upper  part  of  the  body  rests  on  the 
left  breast. 

3.  The  hips  rest  near  the  loAver  left  corner  of  the  table  and  the  body 
extends  diagonally  across  the  table  toAvard  the  right  side. 

4.  The  left  thigh  is  draAAii  up  so  that  it  forms  an  acute  angle  Avith  the 


120 


GYNECOLOGIC    EXAMINATION    METHODS 


body,  and  the  right  thigh  is  draAvn  up  still  more,  and  alloAved  to  drop  over 
the  lower  one.  This  puts  the  patient  in  the  position  shoAvn  in  Figs.  95  and  96. 
It  permits  the  abdominal  wall  and  the  intestines  and  uterus  to  fall  forward. 
Use  of  Sims'  Speculum.  To  introduce  the  speculum,  the  right  labia  are 
raised  thus  exposing  the  vaginal  opening  and  then  the  speculum  point,  Avell 
lubricated,   is   carefully  worked  into   the   opening.     At   the   same   time,   the 


Fig.    95.      Patient    in    Sims'    posture.      Notice    how    the    uiiper    knee 
drops  over  the  under  one. 


perineum  is  pulled  somewhat  backward  with  the 
speculum  i^oint,  in  order  to  give  more  room  for  the 
point  to  slip  in  (Fig.  97).  The  blade  is  then  car- 
ried all  the  way  in.  The  speculum  is  then  grasped 
firmly  and  pulled  backward,  thus  retracting  the 
perineum  and  exposing  the  interior  of  the  vagina 
(Fig.  98). 

As  the  speculum  is  introduced  the  vagina  be- 
comes distended  with  air,  and  when  the  perineum 


Fig.  96.  View  from  above,  show- 
ing the  arm  behind  the  patient. 
(Dickinson — American  Textbook  of 
Obstetrics.) 


INSTRUMENTAL    EXA>J  INATION 


121 


is  retracted  the  cervix  and  anterior  vaginal  wall  may  be  seen.  To  bring  the 
cervix  into  still  better  view,  catch  it  with  the  tenaculimi  forceps  and  bring  it 
slightly  toward  the  opening  (Fig.  99). 

When  Indicated.  The  Sims  speculum  Avith  the  Sims  posture  is  of  decided 
advantage  in  the  following  conditions: 

1.  When  the  bivalve  speculum  fails  to  satisfactorily  expose  the  cervix. 
This  may  be  due  to  the  vaginal  walls  being  so  lax  that  they  fall  about  the 
blades  and  obscui-e  the  cervix  or  it  may  be  due  to  the  vaginal  opening  being  so 
small  that  tlie  l^lades  can  not  be  sufficiently  separated.     Again,  in  some  cases  of 


Fig.   97.     Introducing  the   Sims  speculum. 


Fig.  98.  Speculum  in  place,  and  showing  also 
tlic  method  of  holding  the  same  and  of  keeping  the 
upper   buttock   out   of   the  way. 


inflammation  of  the  uterus  or  about  the  uterus,  the  bivalve  speculum  can  not  be 
opened  sufficiently  because  the  anterior  blade  causes  pain  by  pressure  on  the 
inflamed  structures. 

2.  "When  it  is  desired  to  expose  a  lacerated  cervix  without  spreading  the 
lips  apart.  The  bivalve  speculum,  as  it  is  opened,  separates  the  lips  of  the 
lacerated  cervix,  causing  considerable  distortion  and  making  it  rather  hard  to 
judge  of  the  amount  of  eversion  ordinarily  present.  Again,  the  weight  of  the 
uterus  pushes  the  cervix  into  the  vagina,  in  some  cases  making  the  cervix  ap- 


122 


GYNECOLOGIC    EXAMINATION    METHODS 


pear  longer  than  it  really  is.    In  this  way  the  bivalve  speculum  may  lead  to  an 
erroneous  diagnosis  of  elongation  of  the  cervix. 

3.  When  it  is  desired  to  expose  the  cervix  with  the  least  possible  stretching 
of  the  vaginal  opening.  The  vaginal  opening  may  be  so  tender  that  the 
bivalve  speculum  can  not  be  satisfactorily  opened.  Again,  in  removing  cer- 
vical sutures  after  simultaneous  repair  of  both  cervix  and  perineum,  it  is  im- 
portant to  avoid  stretching  the  newly  healed  perineum.    In  these  cases,  a  nar- 


Fig.   99.      Cervix  caught  with  tenaculum   forceps  and   brought   into  view. 


row  Sims  speculum  introduced  in  the  Sims  posture,  causes  the  vagina  to  bal- 
loon and  exposes  the  cervix  and  vaginal  vault  with  much  less  stretching  of  the 
vaginal  orifice  than  would  be  necessary  with  the  bivalve  speculum. 

4.  When  it  is  desired  to  sound  the  uterus  or  to  dilate  the  cervical  canal  or 
to  make  an  intrauterine  application. 

5.  When  the  vagina  is  to  be  packed,  either  for  holding  the  uterus  forward 
or  for  hemorrhage. 

6.  In  clearing  out  the  uterus  with  the  curet  for  incomplete  miscarriage. 


INSTEUMENTAL    EXAMINATION  123 

111  many  such  cases  where  the  miscarriage  has  just  taken  place,  if  the  patient 
be  placed  in  the  Sims  posture  and  all  the  manipulations  made  carefully,  the 
uterus  may  be  thoroughly  cleared  out  with  but  little  pain  and  hence  without 
an  anesthetic. 

7.  When  treating  a  sinus  or  abscess  opening  in  the  posterior  vaginal 
fornix.  When  making  the  incision  back  of  the  cervix  for  pelvic  abscess,  the 
dorsal  posture  is  the  better  one,  as  the  cervix  may  be  held  out  of  the  way  by 
strong  traction,  but  in  the  after-care  of  the  case,  the  Sims  posture  is  usually 
preferable.  It  causes  the  patient  less  pain  and  gives  much  better  exposure  of 
the  opening  back  of  the  cervix. 

EXCISION  OF  TISSUE 

FROM  CER\^X  FOR  MICROSCOPIC  EXAMINATION 

In  many  cases  the  naked-eye  examination  of  the  cervix  is  not  sufficient  to 
make  a  positive  diagnosis  between  malignant  disease  and  certain  other  affections 
of  the  cervix.  In  a  suspicious  case,  particularly  one  that  resists  treatment,  a 
small  piece  of  the  affected  area  should  be  excised  for  microscopic  examination. 
A  very  convenient  instrument  for  this  purpose  is  the  specimen  scissors  shown 
in  Fig.  86.  With  this  a  small  piece  of  the  suspicious  tissue  may  be  clipped  out 
of  the  cervix.  If  there  is  much  bleeding,  a  suture  may  be  placed  under  the 
bleeding  surface  and  tied.  Usually,  however,  a  styptic  application,  with  a 
firm  vaginal  packing,  Avill  stop  the  bleeding.  The  specimen  excised  from  the 
cervix  and  also  all  curettings  should  at  once  be  placed  in  a  small  bottle  of 
alcohol  (95%)  or  formol  (10%)  and  forwarded  to  the  pathologist. 

EXPLORATION  OF  UTERUS  WITH  SOUND 

Through  the  speculum  the  interior  of  the  uterus  may  be  explored  with 
the  uterine  sound.  The  uterine  sound  (Fig.  100,  a)  is  pliable  so  that  it  may  be 
bent  to  accommodate  it  to  the  uterine  canal  in  different  cases.  It  is  graduated 
so  that  the  exact  depth  of  the  canal  may  be  told.  It  has  a  bulbous  end  so 
that  there  will  be  less  danger  of  its  puncturing  the  uterine  wall. 

Introduction  of  Uterine  Sound 

The  sound  should  not  be  introduced  by  touch,  as  was  formerly  the  custom 
and  as  is  shown  even  in  some  recent  textbooks,  for  when  used  in  that  way  it  is 
very  liable  to  carry  infection  into  the  uterus.  Before  sounding,  the  speculum 
should  be  introduced,  the  cervix  exposed  and  caught  with  a  tenaculum  forceps 
and  the  cervix  and  vicinity  cleansed  with  a  reliable  antiseptic  solution.  Then 
the  sterile  sound  is  introduced  into  the  uterus  without  touching  the  vaginal 
wall.  Before  introducing  the  sound,  the  approximate  location  of  the  fundus 
uteri  should  be  determined  by  bimanual  examination  and  the  sound  should  be 


124  GYNECOLOGIC    EXAMINATION    METHODS 

shaped  and  guided  accordingly.  The  sound  can  usually  be  most  conveniently 
introduced  with  the  patient  in  the  Sims  posture  and  the  cervix  exposed  with 
the  Sims  speculum.  After  the  sound  is  sterilized  do  not  touch  the  intrauterine 
portion  with  the  fingers.  If  the  end  requires  bending,  dip  a  piece  of  absorbent 
cotton  in  a  reliable  antiseptic  solution  and  grasp  the  uterine  portion  of  the 
sound  Avith  this  for  bending.  No  force  should  be  used  in  the  introduction  of 
the  sound,  other  than  is  necessary  to  overcome  a  very  slight  stenosis.  If  the 
sound  does  not  pass  easily  in  the  supposed  direction  of  the  canal,  withdraw  it 
slightly  and  try  in  other  directions.  If  it  does  not  then  pass  easily  or  if  it 
causes  much  pain  it  should  not  be  used  further. 

Information  Obtained  by  Uterine  Sounding- 

As  mentioned  later,  the  introduction  of  the  uterine  sound  is  dangerous 
and  rarely  necessary.  When  it  is  necessary  to  use  it,  the  information  obtained 
should  cover  the  folloAving  points: 

Size  and  Shape  of  Cervical  Canal.  Is  there  stenosis!  If  so,  is  it  located 
at  the  external  os  or  the  internal  os  or  between  the  two!  Is  there  antefiexion 
of  cervix?  This  is  indicated  by  a  sharp  bend  forward  of  the  canal  at  the 
internal  os.  In  such  a  case,  even  Avhen  there  is  no  o])struction,  the  sound  often 
stops  at  this  i)oint  because  it  impinges  on  the  posterior  wall  of  the  canal,  and 
if  force  were  used  the  Avail  AA'ould  be  injured.  Curve  the  sound  sharply  so  as 
to  throAv  the  point  forAvai'd  in  a  direction  to  pass  the  bend. 

Position  of  Body  of  Uterus.  Does  the  point  of  the  sound  pass  in  the 
direction  normally  occupied  by  the  uterine  canal  or  is  the  canal,  and  conse- 
quently the  body  of  the  uterus,  displaced?  If  so,  is  the  displacement  back- 
AAard  or  forAA^ard  or  lateral!  The  direction  of  the  canal  helps  also  in  deter- 
mining AA-hich  of  tAA'o  masses  in  the  pehds  is  the  uterus,  in  cases  in  Avhich  this 
can  not  be  otherwise  determined. 

Length  of  Uterine  Cavity.  Is  there  enlargement  of  the  uterus?  If  so,  to 
Avhat  extent?  In  chronic  intlannnation  and  in  subinvolution  there  is  slight 
enlargement.  In  tumors,  particularly  in  large  intramural  fibroids,  there  may 
be  great  elongation  and  distortion  of  the  uterine  cavity. 

Pain.  There  is  usually  some  pain  as  the  sound  passes  the  internal  os.  In 
certain  cases  of  inflammation  and  of  neuralgic  trouble,  the  pain  is  much 
increased  and  the  excessive  tenderness  may  extend  to  the  entire  endometrium. 

Bleeding.  A  drop  or  tAvo  of  blood  may  folloAv  sounding  AA^hen  the  uterus 
is  normal,  but  many  drops  or  a  slight  stream  folloAA-ing  careful  sounding,  indi- 
cates a  pathologic  condition  of  the  endometrium. 

Contraindications  to  Uterine  Sound 

There  is  considerable  danger  in  the  use  of  the  sound,  even  Avhen  handled 
Avith  care.  It  may  carry  infection  into  the  uterus  or  it  may,  by  the  irritation, 
stir  to  activity  a  chronic  inflammation  or  it  may  injure  the  Avail  of  the  canal 


INSTRUMENTAL    EXAMINATION  125 

or  it  may  perforate  the  iitei-iis  and  enter  the  peritoneal  cavity.    The  danger  of 
perforation  is  especially  marked  in  a  iiterns  recently  pregnant  or  the  seat  of 
malignant  disease.    When  proficiency  in  the  l)imannal  examination  is  acquired, 
the  introduction  of  the  uterine  sound  will  seldom  be  necessary. 
Eemember  the  folloAving  rules  as  to  sounding  the  uterus: 

Do  not  sound  unless  there  is  some  special  reason  for  it. 

Do  not  sound  when  there   is   active   inflammation   in  the  vagina   or 

cervix  with  the  body  of  the  uterus  free  or  when  there  is  an  acute 

or  subacute  salpingitis. 
Do  not  sound  when  there  is  a  suspicion  of  pregnancy. 

If  not  exti-emely  careful,  you  are  liable  in  some  doubtful  case  to  inad- 
vertently sound  a  pregnant  uterus  and  cause  serious  trouble  for  the  patient 
and  for  yourself.  To  avoid  this,  it  is  a  good  plan  always,  just  before  introduc- 
ing the  sound,  to  ask  the  patient,  "When  did  you  menstruate  last!"  and  to 
ask  yourself,  "Is  there  any  suspicion  of  pregnancy  in  this  case!"  If  there  is 
suspicion  of  pregnancy,  put  the  patient  on  some  treatment  that  can  not  inter- 
fere with  pregnancy  and  watch  the  case  until  the  next  menstrual  period.  If 
you  doubt  the  patient's  statement  that  she  is  menstruating  regularly,  tell  her 
that  you  must  see  her  when  menstruating  the  next  time,  that  you  may  deter- 
mine the  nature  of  the  flow.  In  that  way  you  can  determine  Avhether  or  not 
she  really  menstruates. 

EXPLORATION  OF  UTERUS"  WITH  CURET 

The  exploration  of  the  interior  of  the  uterus  with  the  curet,  Avithout 
anesthesia,  is  for  the  purpose  of  removing  pieces  of  tissue  for  microscopic  ex- 
amination. Usually  curetment  under  anesthesia  is  preferable.  In  some  cases, 
however,  there  are  contraindications  to  anesthesia  or  for  some  other  reason  it 
is  thought  best  to  try  to  secure  some  tissue  for  microscopic  examination  so  that 
a  diagnosis  may,  if  possible,  be  made  before  giving  an  anesthetic. 

The  curet  used  for  such  exploration  should  be  small  and  should  have  a 
sharp  cutting  edge  (Fig.  100,  d). 

Method  of  Procedure 

The  preparations  are  the  same  as  for  sounding  the  uterus — in  fact,  ex- 
ploration with  the  sound  should  immediately  precede  exploration  with  the 
curet.  The  slight  dilatation  required  and  the  subsequent  exploration  with  the 
curet,  are  usually  best  carried  out  with  the  patient  in  Sims'  posture. 

In  some  eases  the  cervix  will  readily  admit  this  small  curet  without  dilata- 
tion. Usually,  however,  some  dilatation  is  necessary  and  this  is  most  easily 
effected  with  the  graduated  dilators  (Fig.  100,  b)  of  metal  or  hard  rubber.  Be- 
ginning M'ith  the  small  size,  the  dilators  are  introduced  one  after  another  until 


126 


GYNECOLOGIC    EXAMINATION    METHODS 


the  required  dilatation  is  secured.  The  cervix  is  caught  and  steadied  with  a 
tenaculum  forceps,  while  dilatation  is  being  made.  As  a  substitute  for  uterine 
dilators,  the  ordinary  steel  bougies  for  the  male  urethra  do  very  Avell  in  most 
cases.  If  preferred,  the  dilatation  may  be  effected  with  a  small  bladed  dilator 
(Fig.  100,  c)  or  a  curved  uterine  dressing  forceps.  The  bladed  instrument  is 
introduced  closed  and  then  gradually  opened  sufficiently  to  give  the  required 
dilatation.  This  is  more  painful  usually  and  less  convenient  than  the  gradu- 
ated dilators.    All  the  manipulations  should  be  made  gently,  and  nothing  more 


Fig.  100.  Instruments  for  exploring  the  interior  of  the  uterus.  a.  Uterine  sound.  b.  Three 
graduated  metal  dilators  for  enlarging  the  cervical  canal.  c.  Small  branched  dilator.  d.  Small  ex- 
ploring   curet.      e.    Intrauterine    applicator. 


than  slight  dilatation  should  be  attempted,  as  it  would  cause  too  much  pain. 
This  dilatation  without  anesthesia  is  not  practicable  in  the  virgin,  ordinarily, 
though  in  some  cases  it  can  be  carried  out  very  well. 

A  method  of  securing  a  wider  opening  by  slow  dilatation  is  by  packmg 

the  cervical  canal  with  antiseptic  gauze.    If  carried  out  carefully  this  is  safe, 

and  is  sometimes  effective.    Under  the  same  antiseptic  preparation  as  for  the 

.  other  methods  of  dilatation,  a  thin  strip  of  gauze  is  introduced  into  the  uterus. 


PELVIC    EXA^IINATION    UNDER   ANESTHESIA  .     127 

past  the  internal  os  if  possible,  and  the  cervical  canal  is  packed  firmly  Avith  it, 
the  end  ])eino'  left  ont  of  the  cervix.  This  is  held  in  place  hy  a  vaginal  packing 
of  the  same  material.  The  patient  should  go  to  hed  as  soon  as  she  reaches 
lioine  and  remain  there  until  the  time  for  the  next  treatment.  In  t^venty-four 
hours  the  packing  is  removed  and  the  cervical  canal  is  found  considera])ly 
softened  and  dilated. 

Formerly  tents  were  much  used  for  dilating  the  cervix.  Such  a  tent  was 
simply  a  dry  cone  of  some  substance  Avhich,  when  moist,  gradually  expanded 
with  sufficient  force  to  dilate  the  cervix.  The  dilatation  required  several 
hours  and  sometimes  several  days,  the  patient  in  the  meantime  being  given 
morphine  on  account  of  the  pain.  The  substances  used  Avere  sponge,  laminaria 
and  tupelo.  Many  deaths  Avere  caused  by  infection  resulting  from  the  use  of 
tents,  and  even  in  skilled  hands  and  Avith  all  the  modern  antiseptic  precautions, 
tents  still  cause  serious  trouble  at  times.  Consec|uently  their  use  has  been  al- 
most abandoned.  If  used  at  all,  the  tent  should  be  covered  with  a-  sterilized 
rubber  tent  cover. 

After  the  required  dilatation  has  been  secured,  the  curet  is  introduced  and 
portions  of  the  diseased  endometrium  removed  for  microscopic  examination. 
If  there  is  persistent  bleeding  after  the  use  of  the  curet,  an  intrauterine  appli- 
cation of  a  10  per  cent  copper  sulphate  solution  may  be  used.  If  the  bleeding 
still  persists,  a  small  piece  of  antiseptic  gauze  should  be  packed  firmly  into 
the  uterine  cavity  and  the  vagina  also  packed  Avith  gauze.  The  gauze  may  be 
remoA^ed  in  tAvo  days  and  an  antiseptic  A^aginal  douche  giA^en  once  o'r  twice 
daily  for  a  fcAv  days. 

Contraindications.  The  use  of  the  curet  for  diagnosis  is  contraindicated 
by  the  same  conditions  that  contraindicate  the  sound.  The  use  of  the  curet 
Avithout  anesthesia,  as  just  described,  is  not  nearly  as  satisfactoi'y  as  the  regu- 
lar curetment  under  anesthesia. 

PELVIC  EXAMINATION  UNDER  ANESTHESIA 

The  advantage  of  anesthesia  is  that  it  eliminates  pain  and  muscular  ten- 
sion, the  tAvo  factors  that  make  the  ordinary  pelvic  examination  incomplete 
and  unsatisfactory  in  certain  cases. 

Preparations 

In  preparation  for  this  examination  the  patient's  boAvels  should  be  moved 
Avith  a  purgative  on  the  prcAdous  day  and  the  rectum  should  be  cleared  out  Avith 
an  enema  an  hour  or  tAA'o  before  the  examination.  The  same  preparatory  exami- 
nation of  the  heart,  lungs  and  urine  should  be  made  as  though  the  anesthesia 
were  for  an  operation.  Have  ready  a  light  strong  tenaculum  forceps,  so  that 
the  cervix  may  be  caught  and  the  uterus  pulled  doAvii  as  desired.     If  the  in- 


128  GYNECOLOGIC    EXAMINATION    METHODS      . 

terior  of  the  uterus  is  to  he  explored,  the  autiseptic  preparation  for  curetment 
must  he  carried  out. 

Examination  Methods 

The  various  manipulations  employed  in  examination  under  anesthesia  are 
as  follows: 

Vagino-ahdominal  palpation, 

Eeeto-ahdominal  palpation, 

Recto-vagino-ahdominal  palpation, 

Recto-vesieal  palpation, 

Curetment, 

Exploration  of  interior  of  uterus  with  finger, 

Excision  of  piece  of  cervix  for  examination. 

VAGINO-ABDOMINAL  PALPATION 

In  vagino-abdominal  palpation  under  anesthesia,  the  same  manipulations 
are  employed  and  the  same  facts  concerning  normal  and  abnormal  pelvic 
structures  are  sought,  as  in  the  ordinary  vagino-abdominal  (bimanual)  exam- 
ination. Under  anesthesia,  however,  the  examination  is  much  more  thorough. 
Deep  palpation  may  be  made  in  all  portions  of  the  pelvis,  and  the  uterus,  tubes, 
ovaries  and  abnormal  masses  may  be  clearly  outlined  in  nearly  every  case. 
The  position,  size,  shape,  consistency,  mobility  and  attachments  of  a  pelvic 
mass  may  be  determined  with  far  more  accuracy  than  without  anesthesia. 

In  all  doubtful  eases,  this  method  of  examination  should  l)e  employed  be- 
fore subjecting  the  patient  to  abdominal  section. 

In  the  examination  under  anesthesia,  the  manipulations  must  always  be 
made  carefully  and  gently,  otherwise  a  collection  of  pus  may  be  broken  open 
internally,  causing  peritonitis,  or  the  sac  of  a  tubal  pregnancy  may  be  rup- 
tured, causing  fatal  hemorrhage. 

EECTO-ABDOMINAL  PALPATION 

The  recto-abdominal  palpation  under  anesthesia  is  made  for  the  same  pur- 
pose as  the  vagino-abdominal  palpation  and  in  the  same  way  except  that  two 
fingers  of  the  gloved  hand  are  introduced  into  the  rectum  instead  of  into  the 
vagina. 

Much  additional  information  may  in  this  way  be  obtained  in  some  cases 
because,  under  anesthesia,  the  fingers  can  pass  further  up  the  posterior  surface 
of  the  uterus.  By  catching  the  cervix  with  a  tenaculum  forceps  and  pulling 
the  uterus  downward,  the  posterior  surface  of  the  uterus  and  the  ovaries  and 
the  broad  ligaments  may  be  palpated  with  but  little  intervening  tissue. 

To  get  the  full  benefit  from  this  method,  particular  attention  must  be  paid 


PELVIC    EXAMINATION    irNTDER    ANESTHESIA  129 

to  details.  After  tlie  patient  is  Avell  under  the  anestlietic  and  as  much  infor- 
mation as  possible  has  been  secured  by  vagino-abdominal  palpation,  then  make 
the  reeto-abdominal  examination  as  follows: 

1.  Cleanse  the  rubber  glove  from  all  vaginal  secretion  or  put  on  a  fresh 
one  (that  no  infection  be  carried  into  the  rectum),  and  lubricate  the  glove  with 
a  drop  or  tAvo  of  liquid  soap.  If  the  bare  fingers  have  been  used  for  vaginal 
examination,  cleanse  them  and  put  on  a  rubber  glove.  If  no  rubber  glove  is  at 
hand,  fill  the  space  under  the  nails  of  the  examining  fingers  by  scraping  across 
a  bar  of,  soap  and  then  lubricate  the  fingers  with  a  drop  or  two  of  liquid 
soap  or  with  an  abundance  of  vaseline  or  other  bland  ointment.  If  no  rubber 
glove  is  worn,  the  examining  fingers  should,  immediately  after  the  examina- 
tion, be  dipped  at  once  (before  putting  them  in  soap  and  Avater)  into  a  strong 
antiseptic  solution  (e.  g.,  bichloride  1-1000)  and  scrubbed  in  that  Avith  a  piece 
of  cotton.  After  that  they  are  put  through  the  regular  scrubbing  Avith  soap 
and  Avater  and  a  brush.  This  immediate  cleansing  in  a  strong  antiseptic  solu- 
tion before  the  regular  scrubbing  Avith  soap  and  AA'ater,  aids  in  removing  the 
odor. 

2.  Introduce  tAvo  fingers  into  the  rectum.  Under  the  anesthetic,  the 
sphincter  ani  is  readily  dilated  to  admit  the  tAvo  fingers  as  they  are  carefully 
Arorked  in.  A  much  more  thorough  recto-abdominal  palpation  of  the  pelvic 
interior  may  be  made  Avith  tAvo  fingers  in  the  rectum  than  Avith  only  one. 

The  fingers  are  Avorkecl  past  the  rectal  folds,  up  betAveen  the  sacro-uterine 
ligaments,  Avhich  serA^e  as  landmarks,  and  then  as  far  up  beyond  as  possible. 
The  anus  and  pelvic  fioor  are  pushed  into  the  pelvis  as  far  as  they  Avill  go,  by 
firm  pressure  against  the  elboAv  of  the  examining  arm,  the  elbow  resting  on 
the  knee  or  against  the  hip,  as  in  deep  A^agino-abdominal  palpation.  In  this 
Avay  the  tips  of  the  examining  fingers  may  be  carried  far  up  into  the  posterior 
part  of  the  pelvis. 

There  may  be  some  difficulty  in  finding  the  rectal  canal  in  the  region  of 
the  sacro-uterine  ligaments.  Sometimes  the  interior  of  the  rectum  feels  like 
a  large  pouch  Avithout  any  opening  extending  higher.  If  you  are  satisfied  to 
make  the  pehdc  palpation  by  attempting  to  carry  up  the  Avail  of  this  pouch, 
you  will  be  much  hampered.  By  locating  the  cervix  uteri  and  then  the  two  sacro- 
uterine ligaments  and  Avorking  round  to  get  past  the  rectal  A^ah^es  and  folds,  a 
small  opening  Avill  be  felt  extending  upAvard  betAveen  the  sacro-uterine  liga- 
ments. FoUoAv  this  up  (it  dilates  easily)  and  you  Avill  find  further  progress 
unobstructed.  The  fingers  are  carried  as  high  as  they  Avill  go  and  then  the  ab- 
dominal Avail  is  depressed  from  aboA'-e  b}^  the  other  hand  (Fig.  101). 

3.  The  various  structures  in  the  i)Osterior  and  central  parts  of  the  pehns 
are  then  caught  betAveen  the  hands  and  outlined  and  otherAvise  examined  by 
palpation,  one  at  a  time.  The  palpation  proper  is  made  principally  AAdth  the 
rectal  fingers,  the  abdominal  fingers  serving  simply  to  push  doAvn  the  struc- 
tures to  Avithin  reach  of  the  fingers  beloAV.     In  this  ])al])ation,  the  guide  is  the 


130    '  GYNECOLOGIC   EXAMliSTATlON    METHODS 

bod}^  of  the  uterus.  The  fingers  pass  up  the  posterior  surface  of  the  uterus 
to  the  fundus  and  then  out  to  the  lateral  region  of  each  side,  palpating  the 
tube  and  ovary  and  any  abdominal  mass.  In  a  patient  with  only  a  moderately 
thick  abdominal  wall,  the  ovaries  and  tubes  may  be  distinctly  outlined,  unless 
they  are  obscured  by  adhesions  or  by  an  inflammatory  mass  or  by  a  tumor. 

4.  Then  catch  the  cervix  with  a  tenaculum  forceps  and  draw  it  down 
gently,  and  have  someone  hold  the  forceps  to  keep  the  uterus  in  the  downward 
position.  This  drawing  downward  and  forward  of  the  cervix,  throws  the  fun- 
dus backward  so  that  it  is  caught  between  the  rectal  fingers  and  the  abdom- 
inal fingers,  and  its  size,  shape,  consistency,  mobility  and  attachments  may 
all  be  accurately  made  out. 

The  fingers  then  pass  to  the  adnexa,  determining  the  same  points  con- 
cerning them. 

If  there  is  a  movable  mass  of  doubtful  origin,  have  some  one  catch  it  from 
the  abdominal  surface  and  pull  it  up  towards  the  abdominal  cavity  so  that  the 


Fig.    101.      Recto-abdominal    palpation.      The    hand   should    be    gloved.       (Montgomery — 

Practical    Gynecology.) 

examining  fingers  (rectal  and  abdominal)  may  meet  between  the  mass  and  the 
pelvic  structures.  In  this  way,  the  pedicle  of  the  mass  (if  it  arises  from  the 
pelvis)  ma}^  be  felt  and  traced  to  its  origin,  and  also  its  length  and  thickness 
determined  (Fig.  102).  This  is  sometimes  referred  to  as  Hegar's  method  of 
examining  the  pedicle  of  a  tumor. 

5.  Cautions.  Particular  care  must  be  exercised  that  the  structures  be  not 
injuriously  pressed  or  pulled  upon,  for  as  the  patient  is  anesthetized  the  usual 
warning  complaint  of  pain  is  absent.  There  are  three  points  that  it  may  be 
well  to  mention  particularly: 

(a)  Do  not  use  much  force  in  palpation.  A  pus  sac  may  be  broken, 
causing  peritonitis,  or  a  tubal  pregnancy  may  be  disturbed  sufficiently  to 
cause  a  fatal  hemorrhage.  In  fact,  a  patient  with  suspected  tubal  pregnancy 
should  not  be  examined  under  anesthesia  until  she  is  got  to  the  hospital  or 


PELVIC   EXAMINATION   UNDER   ANESTHESIA 


131 


until  things  are  ready  in  the  home,  so  abdominal  section  could  be  carried  out 
immediately  should  threatening  symptoms  arise  during  the  examination. 

Again,  if  much  force  is  used  the  examining  fingers  may  be  pushed  through 
the  rectal  Avail  into  the  peritoneal  cavity.  Kelly  mentions  cases  in  "which  this 
accident  occurred  and  in  which  immediate  abdominal  section,  or  vaginal  sec- 
tion, was  carried  out  to  repair  the  rent  in  the  bowel  wall  and  prevent  fatal 
peritonitis. 

(b)  Do  not  draw  down  the  uterus  very  far  nor  very  forcibly,  for  reasons 
already  given.  It  is  a  good  rule  to  bring  the  uterus  down  no  further  than  is 
absolutely  necessary  to  satisfactorily  palpate  it.  In  most  of  these  cases  all  that 
is  necessary  is  a  slight  downward  displacement,  that  permits  the  fundus  to  go 
somewhat  backward  so  that  it  can  be  grasped  well  between  the  rectal  fingers 
behind  and  the  abdominal  fingers  in  front.  The  extreme  downward  displace- 
ment of  the  cervix,  to  the  vaginal  entrance  or  even  outside,  is  not  necessary  nor 
advisable,  except  in  cases  where  there  is  already  prolapse  of  the  uterus.    The 


Fig;  102.  Palpating  the  pedicle  of  a  tumor,  with  the  tumor  pushed  up  into  the  abdominal 
cavity  and  the  uterus  caught  with  a  tenaculum  forceps  and  pulled  downward.  (Montgomery — 
Practical    Gynecology.) 

occasion  for  it  does  arise  if  the  fingers  are  carried  up  the  rectum  by  invagina- 
tion of  the  pelvic  floor,  as  above  described. 

(c)  The  suggestion  to  use  the  whole  hand  in  the  rectum  for  exploration  in 
difficult  cases,  was  long  ago  made  and  carried  out  with  disastrous  results. 
This  method  should  not  be  used.  It  has  led  to  rupture  of  the  rectum,  with 
fatal  peritonitis.  Furthermore,  no  need  for  it  is  experienced  if  the  palpation 
with  two  fingers  is  carried  out  with  close  attention  to  the  details  above  given. 


RECTO-VAGINO-ABDOMINAL  PALPATION 

In  some  cases,  additional  information  may  be  obtained  by  this  method. 
AVith  the  two  fingers  in  the  rectum,  the  thumb  of  the  same  hand  is  passed  into 
the  vagina  and  the  lower  part  of  the  pelvic  mass  or  of  the  uterus  is  grasped  be- 


132  GYNECOLOGIC    EXAMINATION    jVIETHODS 

tween  the  fingers  and  the  tluinih,  the  strnctures  being  pressed  down  withm 
reach  by  the  abdominal  hand  (Fig.  103). 

In  some  cases,  this  is  of  decided  assistance  in  outlining  a  small  mass  low 
in  the  pelvis  and  in  determining  the  exact  consistency  of  different  parts  of  it. 
In  certain  cases,  where  there  is  a  wide  vaginal  opening  and  relaxed  pelvic 
floor,  the  examiner  may  palpate  the  nterns  or  other  mass  Ioav  in  the  pelvis, 
Avith  almost  as  much  accuracy  as  though  it  were  removed  and  lying  free  in 
the  hand. 

A  modification  of  this  method  is  to  introduce  the  middle  finger  into  the 
rectum  and  the  index  finger  into  the  vagina  and  palpate  the  structures  between 


Fig.  103.  Recto-vagino-abdominal  palpation.  One  or  two  fingers  of  the  gloved  hand  are  intro- 
duced into  the  rectum  and  the  thumb  into  the  vagina,  and  the  uterus,  or  other  mass  low  in  the 
pelvis,  is  grasped  between  them,  as  it  is  pushed  down  by  the  abdominal  hand.  (Montgomery — 
Practical     Gynecology.) 

the  fingers  as  the  uterus  is  pushed  down  from  above.  This  method  of  recto- 
vagino-abdominal  palpation  has  been  found  useful  in  determining  the  extent 
of  involvement  of  the  parametrium  in  cases  of  carcinoma  of  the  cervix  uteri. 


RECTO-VESICAL  PALPATION 

In  the  tecto-vesical  palpation  under  anesthesia,  a  medium  sized  urethral 
bougie  (about  21  F)  is  introduced  into  the  bladder,  and  one  or  tAVo  fingers 
into  the  rectum.  The  tissues  betAA'een  the  rectum  and  the  end  of  the  bougie 
are  carefully  palpated  by  the  i-ectal  fingers.  This  method  is  used  in  only  tAA'o 
conditions — (a)  in  determining  the  presence  or  absence  of  the  uterus  in  cases 
of  atresia  of  vagina  and  (b)  in  distinguishing  betAA^een  inversion  of  the  uterus 
and  a  large  pedunculated  fibroid  hanging  from  the  cervix.  In  a  very  stout 
patient,  this  method  may  be  the  only  means  of  making  a  positive  diagnosis  in 


PELVIC    EXAMINATION    UNDER    ANESTHESIA 


133 


the  classes  of  eases  mentioned.  If  the  bladder  is  not  irritable,  this  method 
may  be  employed  gently  Avithout  anesthesia,  but  the  examination  under  anes- 
thesia is  far  more  satisfactory. 


Fig.  104.  Curetting.  Glandular  Hyperplasia  of 
the  Endometrium.  The  glands  are  sectioned  longi- 
tudinally,   showing   the   cork-screw    shape. 


C^ 


Fig.  105.  Same  curettings  of  a  Glandular  Hyper- 
plasia of  Endometrium,  sectioned  transversely. 
Glands  lumina  lying  close  to  each  other. 


^ 

% 

'.y 

;••- 

•»  ■'. 

■  ■  x"  i 

' 

V  ^■■'r 

-■">. r^- .. 

-^--J'    ■  ■. 

^- , ' 

'     '  '  *  "^»  •     •  ■ 

'V  "*        ♦  •        '♦ 


<■  -'.-vlfi^i.^.' 


Fig.     106.       Curetting.       Interstitial     Hyperplasia     of 
the    Endometrium.       Low    power. 


Fig.     107.       Curetting.       Interstitial     Hyperplasia     of 
the    Ivndomctrium.      High    power. 


134  GYNECOLOGIC    EXAMINATION    INIETHODS 

Caution.  Palpation  with  the  finger  introduced  through  the  dilated  ure- 
thra, the  author  mentions  only  to  condemn.  It  is  dangerous  in  that  it  is 
liable  to  cause  permanent  incontinence  of  urine,  a  condition  which  resulted  in 
several  reported  cases. 

GUEETMENT  UNDER  ANESTHESIA 

Curetment  for  diagnostic  purposes  is  carried  out  the  same  as  regular 
curetment  for  therapeutic  purposes.  By  it  tissue  is  obtained  from  all  por- 
tions of  the  endometrium  for  microscopic  examination.  As  previously  stated, 
this  is  much  more  satisfactory  than  the  partial  curetment  without  anesthesia, 
for  by  the  curetment  under  anesthesia,  tissue  is  removed  from  j)ractically  all 
parts  of  the  cavity.  Consequently,  if  in  the  subsequent  microscopic  examina- 
tion no  malignant  tissue  is  found,  we  may  be  fairly  certain  that  there  is  no 
malignant  disease.  Furthermore,  regular  curetment  under  anesthesia  com- 
bines with  its  diagnostic  value  a  decided  therapeutic  effect,  for  it  removes  the 
diseased  endometrium  and  diminishes  bleeding  and  discharge.  As  will  appear 
later,  curetment  is  often  indicated  in  a  particular  ease  by  both  therapeutic 
and  diagnostic  considerations.  For  example,  when  a  patient  has  uterine 
bleeding  or  discharge  that  resists  ordinary  treatment,  curetment  is  indicated 
to- stop  the  bleeding  or  discharge  and  also  to  furnish  tissue  for  microscopic 
examination. 

Of  the  various  conditions  that  give  rise  to  persistent  bleeding  and  dis- 
charge the  following  produce  characteristic  changes  in  the  endometrium: 

Chronic  endometritis. 
Hyperplasia  (Figs.  104,  105,  106,  107), 
Malignant  disease  (Figs.  108,  109), 
Tuberculosis  of  the  endometrium. 
Recent  abortion  (Figs.  110,  111). 

There  are  other  conditions,  for  example,  extrauterine  pregnancy,  in  which 
the  microscopic  appearance  of  the  curettings  is  not  pathognomonic  but  in 
which  the  information  obtained  in  this  way,  added  to  the  symptoms,  may  make 
the  diagnosis  positive  in  an  otherwise  doubtful  case. 

Collecting'  Curettings 

In  a  diagnostic  curetment,  observe  the  following  points: 

1.  Remove  the  endometrium  from  all  parts  of  the  uterine  cavity. 

2.  Put  all  the  curettings  directly  into  a  small  vessel  and  shake  with  water 
to  remove  blood-clots.  If  the  water  is  so  bloody  that  it  is  desired  to  change 
it  for  further  washmg,  it  is  poured  through  gauze.  The  gauze  catches  the 
curettings,  which  are  then  emptied  into  fresh  water.  The  water  into  which 
curettings  are  placed  should  be  clear  and  clean.     Normal  saline  solution  is 


PELVIC    EXAMINATION   UNDER   ANESTHESIA 


135 


^P  .M^'-' 


Fig.    108.      Curetting.       Adenocarcinoma     of     the 
Endometrium.      L,ow  power. 


Fig.   109.     Curetting.     Adenocarcinoma  of  the 
Endometrium.      High    power. 


Fig.   110.      Curretting.      Incomplete    Abortion. 
Chorionic    tissue    and    blood, 


Fig.  111.  Curetting.  Incomplete  Abortion.  An- 
other case.  Typical  chorionic  villi  and  a  few  decidual 
cells,  left   upper   corner. 


136  GYNECOLOGIC    EXAMINATION    METHODS 

preferable  to  i3lain  water  as  it  causes  less  swelling  of  the  cells,  hence  it  should 
be  used  for  the  washing  when  the  curettings  are  to  be  subjected  to  any  par- 
ticular or  special  examination. 

3.  Then  transfer  all  the  tissue  fragments,  without  compression,  to  a 
small  bottle  containing  95%  alcohol  or  10%  formol  solution  and  send  to  the 
laboratory. 

4.  If  the  pathologist  is  in  a  distant  city,  the  little  bottle  should  be  corked 
securely  and  put  in  a  mailing  tube  or  wrapped  with  cotton  and  otherwise 
packed  securely  for  safe  transmission. 

5.  With  the  specimen,  send  a  note  stating  the  nature  of  the  specimen 
(curettings  from  within  uterus),  when  obtained,  name  and  age  of  patient 
and  some  of  the  important  facts  in  the  history  of  the  case. 

EXPLORATION  OF  UTERINE  CAVITY  M^ITH  FINGER 

Exploration  of  the  interior  of  the  uterus  with  the  finger  may  be  employed 
when  satisfactory  information  can  not  be  obtained  otherwise.  The  cervix  may 
he  dilated  in  the  same  manner  as  for  curetment,  i.  e.,  with  a  strong  bladed 
dilator,  but  the  dilatation  must  be  carried  much  further,  as  it  takes  a  larger 
opening  to  admit  the  finger  than  to  admit  the  curet.  The  dilatation  required 
for  satisfactory  exploration  with  the  finger  must  be  so  wide  that  it  is  only  in 
exceptional  cases  that  it  can  be  secured  in  the  non-puerperal  uterus  with  the 
ordinary  dilator. 

To  secure  satisfactory  dilatation,  Schatz's  metranoikter  may  be  used. 
This  consists  of  two  blades  separated  by  a  strong  spring.  They  are  intro- 
duced into  the  cervix  closed.  The  removal  of  the  introducing  handle  releases 
the  spring  which  gradually  effects  wide dilatation  of  the  cervix,  within  twelve 
to  tAventy-four  hours.  The  pain  is  controlled  by  morphine.  This  instrument 
causes  Avide  dilatation  and  may  be  used  in  preparation  for  examination  under 
anesthesia  where  for  some  particular  reason  it  is  desired  to  palpate  the  interior 
of  the  uterus.  It  may  be  used  also  to  dilate  the  cervix  for  curetment  without 
anesthesia  or  even  for  exploration  of  uterus  with  the  finger  without  anesthesia. 

Hirst  has  modified  the  Schatz  metranoikter,  making  it  with  four  blades 
instead  of  two. 

A  more  certain'  and  satisfactory  method,  when  the  patient  is  given  an 
anesthetic,  is  to  dilate  the  cervical  canal  to  the  usual  extent  with  the  regular 
l)laded  dilator  and  then  divide  the  Avail  of  the  cervix  with  a  knife  or  scissors, 
in  the  median  line  anteriorly  up  to  or  above  the  internal  os.  The  bladder  must 
of  course  first  be  separated  from  the  cervix  and  pushed  up  out  of  the  Avay. 
This  alloAvs  a  thorough  exploration  of  the  interior  of  the  uterus  AA-ith  the 
finger.  It  is  a  rather  formidable  procedure  for  exploration  alone  and  usually 
is  employed  only  after  preparations  have  been  made  to  do  a  hysterectomy  or 
other  operation  immediately  after  the  exploration,  if  such  is  found  necessary. 

After  sufficient  dilatation  lias  been  obtained  by  one  of  the  methods  men- 


PELVIC    EXAMINATION    UNDER   ANESTHESIA  137 

tiuiied,  the  finger  is  iiitroduced  into  the  uterine  cavity  and  the  vails  palpated, 
the  uterus  at  the  same  time  being  pushed  downAvard  and  steadied  by  the  other 
hand  the  same  as  in  bimanual  examination.  Some  additional  information  may 
be  obtained  by  this  method,  for  example,  we  may  determine  the  presence  of 
irregularities  of  the  uterine  wall,  of  projecting  growths,  of  softened  or  broken 
down  places  or  of  areas  of  induration. 

Exploration  of  the  uterine  cavity  with  the  finger  is  seldom  necessary  in 
the  non-puerperal  uterus.  In  all  but  exceptional  cases,  the  diagnosis  may  be 
made  without  it.     In  the  puerperal  uterus,  it  is  exceedingly  useful  for  deter- 


Fig.     112.       Exploration    of    the    interior    of    the     uterus    with    the     finger.       This    represents    a    puerperal 
uterus    with    retained    placental    remnants.      (Edgar — Practice    of    Obstetrics.) 

mining  the  presence  of  placental  remnants  (Fig.  112)  and  for  safely  clearing 
out  the  same.  In  the  recently  pregnant  uterus  no  special  dilatation  measures 
are  necessary  because  the  cervix  is  so  soft  that  abundant  dilatation  is  secured 
with  the  ordinary  bladed  dilator  or  in  some  cases  even  with  the  finger  alone. 

INSPECTION  OF  THE  UTERINE  INTERIOR 

The  metroscope  is  an  electrically  lighted  endoscopic  tube  adapted  in 
length  and  caliber  to  viewing  the  interior  of  the  uterus.  Its  use  may  be  advis- 
able in  rare  conditions,  but  the  fact  must  be  recognized  that  the  additional 
information  it  gives  is  very  slight  and  is  more  than  over-balanced  by  the 
danger  that  will  result  from  its  general  use. 

RADIOGRAPHY 

The  Rontgen-ray  examination  has  proved  invaluable  in  the  differential 
diagnosis  of  pelvic  conditions,  especially  in  the  differentiation  of  ureteral, 
bladder  and  intestinal  lesions.  It  is  of  help  also  in  advanced  cases  of  extra- 
uterine pregnancy,  in  dermoid  cysts  with  teeth,  and  in  suspected  foreign  bodies 
(instrument  left  at  operation).  In  certain  exceptional  cases  valuable  help  in 
diagnosis  may  be  obtained  by  introducing  a  sound  or  bai'iuni  mixtui-e  into  the 


138  GYNECOLOGIC  exa:mixation  isiethods 

corpus  uteri,  and  then  identifying  it  by  fluoroscope  and  plates.  The  suggestion 
also  has  been  made  to  answer  the  question  of  the  permeability  of  the  Fallopian 
tubes  in  eases  of  sterility,  by  intrauterine  and  intratubal  injection  of  barium 
mixture  folloAved  by  X-ray  examination.  Such  investigations  should  be  car- 
ried out  only  under  very  strict  precautions  and  by  experienced  gynecologists. 
The  danger  from  such  injections  is  very  decided,  the  benefits  so  far  reported 
have  been  practicalh^  nil. 

Peterkin  (Urologic  and  Cutaneous  Review,  Vol.  XVIII,  1914)  devised  a 
method  of  determining  the  relation  of  the  uterus  to  the  bladder  and  ureters 
and  pelvic  walls  (e.  g.,  in  prolapse)  by  inserting  a  special  metal  plug  in  the 
cervix  uteri  and  then  employing  radiography. 

EXCISIOX  OF  TISSUE  FROM  CERVIX 

Excision  of  a  piece  of  tissue  from  the  cervix  for  microscopic  examination 
may  be  quickly  carried  out  following  curetment  or  other  exploratory  exam- 
ination, when  thought  advisable.  In  this  Avay  a  positive  diagnosis  of  malig- 
nant disease  of  the  cervix  may  be  made  in  the  early  stage.  This  aid  to  diag- 
nosis should  be  carried  out  during  the  examination  under  anesthesia  whenever 
a  suspicious  ulcer  or  induration  is  present.  A  small  wedge-shaped  portion  of 
the  suspicious  area,  including  some  healthy  tissue,  is  excised  and  the  wound 
thus  made  is  closed  by  one  or  two  sutures.  The  sutures  should  be  left  in  place 
about  ten  days,  the  patient  in  the  meantime  receiving  one  or  two  antiseptic 
douches  daily.    She  need  not  remain  in  bed. 

PREPARATIONS  FOR  GYNECOLOGIC  EXAMINATION 

The  various  points  considered  under  this  head  may  be  grouped  as  folloAvs: 
Office  Arrangements. 
Directions  to  Patient. 
Antiseptic  Preparations. 
Soap,  Brushes,  Lubricant. 
Use  of  Rubljer  CtIovbs. 
Avoid  Unnecessary  Exposure. 
Preservation  of  Specimens. 
Examination  on  Bed. 

OFFICE  ARRANGEMENTS 

There  are  three  things  of  particular  importance  in  the  handling  of  gyne- 
cologic iDatients: 

1.  Screened  Area  in  the  Consulting  Room.  The  portion  of  the  room  that 
is  used  for  the  examination  should  be  suitably  screened  from  the  other  part,  so 
that  the  patient  may  remove  the  corset  and  make  such  other  arrangement  of 
the  clothing  as  she  wishes,  in  privacy.    It  is  very  convenient  to  have  a  separate 


PREPARATIONS   FOR   EXAMINATION 


139 


room  for  the  examiniiig-room,  with  an  attached  toilet-room.  Where  no  sepa- 
rate room  is  available,  a  neat  substantial  screen,  affording  the  patient  privacy 
for  the  required  preparation,  does  very  well  and  is  inexpensive. 

2.  Table.  A  satisfactory  table  for  gynecologic  examinations  is  the  reg- 
ular surgical  chair  with  footrests.  The  advantage  of  the  footrests  is  that  the 
patient's  hips  may  be  brought  to  the  end  of  the  table  without  her  feet  being 
forced  so  near  the  buttocks  as  to  be  uncomfortable. 


Fig.    113.     Kitchen  table,   with  portable  foot-rests  attached   ready  for   a  gynecologic  examination. 


In  the  absence  of  the  surgical  chair,  portable  footrests  may  be  attached 
to  a  plain  kitchen  table  (Fig.  113).  With  these  portable  footrests  are  fur- 
nished also  tall  uprights  for  use  as  legholders,  by  which  the  feet  and  legs  may 
be  held  out  of  the  way  during  examination  under  anesthesia  or  during  an 
operation.  They  are  convenient  for  use  during  minor  operations  at  the  pa- 
tient's home. 

3.  Nurse.  When  a  physician  is  doing  much  gynecologic  work  it  will 
be  found  a  wise  investment  to  have  a  nurse,  to  prepare  the  patients  for  ex- 


140  GYXECOLOGIC    EXAMIXATIOX    METHODS 

amiiiatioii  and  to  prepare  the  necessary  articles  needed  in  office  examination 
and  treatment.  Aside  from  the  great  convenience  to  the  pliysician,  it  malves 
the  patients  more  at  ease  and  in  addition  tends  to  protect  the  physician  from 
blackmail  by  designing  persons.  AVhere  a  nnrse  is  not  required  for  other 
Avork,  she  may  be  hired  just  for  the  office  hours  and  thus  the  expense  reduced. 

DIRECTIONS  TO  PATIENT 

Direct  the  patient  to  remove  the  corset  and  loosen  all  bands  about  the 
Avaist,  so  that  the  clothing  may  be  pushed  up  and  down  sufficiently  to  bare  the 
abdomen.  This  is  necessary  at  first,  for  the  first  examination  should  be 
thorough,  including  examination  of  the  entire  al)domen  as  well  as  the  pelvic 
exploration.  Examination  of  the  breasts  may  be  necessary  in  cases  of  sus- 
pected pregnancy.  If  there  are  indications  of  disease  of  the  heart  or  lungs, 
those  organs  also  should  be  examined,  and  the  same  is  true  of  the  nervous 
system. 

In  the  subsequent  visits,  it  may  not  be  necessary  to  remove  the  corset  or 
loosen  the  clothing,  depending  of  course  on  what  treatment  or  further  exam- 
ination is  recjuired.  It  is  not  necessary  in  ordinary  cervical  or  vaginal  treat- 
ments. Any  treatment  however  necessitating  deep  bimanual  palpation,  such 
for  example  as  replacement  of  a  retrodisplaced  uterus,  requires  the  removal 
of  the  corset  and  loosening  of  bands. 

After  completing  the  al)dominal  examination,  direct  that  the  hips  be 
brought  to  the  foot  of  the  table.  The  patient  is  covered  with  a  clean  sheet 
and  under  the  sheet  the  skirts  are  pushed  up  above  the  knees  and  out  of  the 
way.  The  sheet  is  then  parted  so  as  to  expose  the  genitals  only,  being  draped 
so  as  to  cover  other  parts.  It  is  well,  as  a  rule,  to  inspect  the  genitals,  for  often 
information  of  value  is  obtained  in  cases  where  the  history  gives  no  intimation 
of  disturbance  externally.  If  it  is  thought  unnecessary  to  inspect  the  genitals, 
the  hand  is  carried  under  the  sheet  for  making  the  vaginal  and  vagino- 
abdominal examination. 

ANTISEPTIC  PREPARATIONS 

If  you  Avish  to  protect  your  patient  and  likcAvise  your  hands  from  the 
danger  of  infection,  certain  antiseptic  precautions  must  be  taken.  The  neces- 
sary measures  are  simple  and  easily  carried  out,  and  if  employed  regularly 
become  more  or  less  of  a  hal)it. 

The  needed  disinfection  wi]]  ])c  indicated  hy  iiamiiig  the  dangers  to  bs 
avoided,  Avhich  are  as  folloAvs: 

1.  Infection  of  the  ])atient  from  your  liands.  If  your  hands  are  A\'ell 
cleansed  before  each  exainination,  there  can  be  no  infection  from  them. 

2.  Infection  of  youi-  liands  from  the  patient.  If  there  is  a  scratch  or 
aln-asioii  aiiywliere  aliout  the  fingei-s,  the  hand  shonhl  l)e  (M)\-cred  Avith  a  rul')l)er 


PREPARATIONS    FOR    EXA^flNATION  141 

glove  (Fig.  49).  If  no  rul)])er  glove  is  at  hand,  a  riil)l)ei'  lingei'-eot  slionld  1)e 
slipped  over  the  al)raded  tingei-  oi-  the  abrasion  covered  with  collodion  spread 
over  a  few  fi1)ers  of  cotton.  If  the  collodion  rubs  off  during  the  examination 
of  a  patient  with  syphilis  or  chancroid  or  other  infectious  disease,  the  abra- 
sion must  be  immediately  touched  with  pure  carbolic  acid  or  nitric  acid  and 
again  covered  with  collodion.  We  hear  a  great  deal  about  the  danger  of  the 
patient  becoming  infected,  but  very  little  about  the  danger  to  the  physician; 
and  yet  there  are  few  physicians  of  experience  who  do  not  number 
among  their  professional  friends,  one  or  more  who  have  become  infected  with 
syphilis  through  abrasions  of  the  hands.  Dudley  states  that  he  is  acquainted 
M'ith  not  less  than  twenty  physicians  who  have  been  infected  with  syphilis 
through  abrasions  of  the  fingers  in  digital  examinations.  Each  physician  must 
look  out  for  himself  and  his  family.  Eemember  that  "prevention  is  better 
than  cure,"  and,  it  ma}^  be  added,  a  great  deal  easier. 

3.  Infection  of  the  patient  from  instruments.  If  the  insti'uments  are 
sterilized  each  time  before  use,  there  can  be  no  danger,  from  them. 

4.  Infection  of  the  patient  from  the  table.  To  prevent  this,  place  under 
the  patient's  hips  a  rubber  pad  or  piece  of  rubber  cloth  and  over  that  a  clean 
folded  towel,  or  a  sheet  of  white  paper,  which  is  changed  with  each  jDatient. 

Precautions.  The  precautions  to  be  taken  in  order  to  avoid  infection  may 
be  summed  up  in  three  rules,  as  follows : 

1.  Disinfect  and  Protect  the  Hands.  Trim  the  finger-nails  short  and  clean 
under  them.  Cleanse  the  hands  well  with  soap  and  water  and  dry  them  with  a 
clean  towel.    Protect  any  abrasion  on  the  hand  with  a  clean  rubber  glove. 

If  there  is  any  break  in  the  protecting  epithelial  layer  of  the  vulva  or 
vagina  or  cervix,  or  if  the  interior  of  the  uterus  is  to  be  explored,  the  hands 
should  be  further  cleansed  in  1-2000  bichloride  or  other  reliable  antiseptic  solu- 
tion (i.  e.,  they  should  be  put  through  the  regular  process  of  surgical  disin- 
fection) or  boiled  rubber  gloves  may  be  slipped  on. 

2.  Sterilize  the  Instruments.  This  may  be  accomplished  by  soaking  them 
in  pure  carbolic  acid  (95%)  for  ten  minutes  or  in  a  10%  carbolic  solution  for 
thirty  minutes.    A  safer  plan  is  to  boil  them  for  five  or  ten  minutes. 

For  boiling  the  instruments,  a  1%  solution  of  sodium  carbonate  (washing 
soda)  is  preferable  to  plain  water.  It  dissolves  the  resisting  capsule  of  bac- 
teria and  destroys  them  more  quickly  (in  five  minutes  boiling)  and  also  tends 
to  diminish  rusting  of  instruments.  Any  kind  of  a  pan,  set  on  a  stove  or  over 
an  alcohol  lamp  or  gas  flame,  will  do  for  an  instrument  boiler.  The  ordinary 
fish-boiler  of  granite-iron  makes  a  very  good  instrument  sterilizer.  A  satis- 
factory simple  boiler  for  instruments  is  shown  in  Fig.  114.  Nicer  and  more 
convenient  instrument  boilers  may  be  purchased  as  desired.  There  are  a 
number  of  satisfactory  patterns.  The  one  shoAvn  in  Fig.  115  has  the  advantage 
that  the  dressings  for  a  small  operation  may  be  sterilized  at  the  same  time  with 
the  instruments. 


142 


GYNECOLOGIC    EXAMINATION    METHODS 


111  office  or  clinic  Avork  when  tlirongii  examining  a  patient,  wash  the 
instruments  and  drop  them  into  the  boiler  and  in  a  few  minutes  they  are 
sterilized,  ready  to  use  for  another  patient-  or  to  be  put  away.  Edged  instru- 
ments, such  as  knives  and  scissors  are  more  or  less  dulled  by  the  boiling.  Con- 
sequently when  there  is  plenty  of  time,  it  is  better  to  sterilize  them  by  soaking 
them  in  carbolic  acid  or  other  suitable  antiseptic.  When  a  knife  is  put  in  with 
other  instruments  for  sterilization  the  cutting  portion  should  be  wrapped 
with  cotton. 

The  instrument  tray  also  must  of  course  be  sterile.  It  is  contaminated 
every  time  a  soiled  instrument  is  laid  back  in  it  and  unless  disinfected  may 
carry  disease  from  one  patient  to  another.  To  obviate  this,  each  instrument 
after  use  may  be  laid  on  a  clean  towel  (if  it  is  to  be  used  again  during  that 
examination)  or  dropped  in  a  basin  for  later  cleansing.  Again,  a  light  shal- 
low pan  may  be  used  as  an  instrument  boiler  and  instrument  tray  combined, 


Fig.    114.      A    simple   instrument    boiler. 


Fig.  lis.  A  small  instrument  and  dressing  ster- 
ilizer. The  dressings  for  a  small  operation  may- 
be sterilized  in  the  trays  above  the  boiling  instru- 
ments. 


the  instruments  being  boiled  in  it  each  time  before  use.  This  gives,  in  a  few 
minutes,  sterile  instruments  in  a  sterile  container. 

3.  Do  not  Touch  the  Intrauterine  Part  of  any  Instrument.  This  rule  should 
be  very  carefully  observed,  for  in  it  lies  one  of  the  secrets  of  avoiding  infec- 
tion of  the  uterine  cavity  in  office  examination  and  treatment. 

The  hands  may  have  been  well  disinfected  or  they  may  have  been  covered 
with  boiled  rubber  gloves,  giving  a  perfectly  sterile  covering,  but  in  office 
work  the  field  of  examination  has  not  been  disinfected.  The  hands  necessarily 
touch  undisinfected  surfaces  and  hence  do  not  remain  sterile.  Consequently, 
when  handling  an  instrument  for  intrauterine  work,  it  is  important,  even  when 
wearing  rubber  gloves,  to  observe  the  rule  not  to  touch  that  part  of  the  in- 
strument that  is  to  enter  the  cervical  canal.  When  bending  the  end  of  the 
uterine  sound,  dip  a  large  piece  of  absorbent  cotton  in  a  reliable  antiseptic  solu- 
tion and  grasp  the  part  to  be  moulded  with  that.  If  the  uterine  canal  is  to  be 
cleansed  with  a  cotton-wrapped  applicator,  use  one  of  those  previously  pre- 


fUEPAltATIONS   FOR   EXAMINATION 


143 


Fig.  116.  The  articles  needed  for  preparing  for  the  gynecologic  examination,  arranged  con 
veniently  on  a  stand,  a.  Finger-nail  instruments,  b.  Rubber  gloves,  c.  Powder  for  dusting  in  rub 
ber  gloves,  to  make  them  slip  on  easily.  d.  Liquid  soap-  in  a  drop-bottle.  e.  Hand  brushes.  / 
Bichloride    solution.      fir.    Cotton    balls.      h.    Lubricant    in    compressible    tube. 


Fig.    117.      Method    of    using    the    drop-bottle     containing    liquid    soap. 


144  GYNECOLOGIC    EXAMINATION    METHODS 

pared,  as  described  under  intrauterine  treatment  in  Chapter  iii.  If  one  must 
be  prepared  for  immediate  use,  be  sure  to  cleanse  carefully  the  fingers  that 
touch  the  cotton  and  also,  before  introducing  the  cotton,  dip  it  in  an  antiseptic 
solution. 

The  other  antiseptic  precautions  necessary  in  intrauterine  exploration  and 
treatment  have  already  been  given. 


SOAP,  BRUSHES,  LUBRICANT 

Soap.  Use  some  liquid  preparation  of  green  soap.  The  free  use  of  such  a 
soap  is  the  most  important  step  in  hand  disinfection.  A  number  of  excellent 
and  convenient  preparations  of  liquid  soap  have  been  put  on  the  market  by 
various  firms,  in  drop  bottles  (Fig.  116,  d)  from  which  the  soap  may  be 
dropped  as  needed  without  waste.  Such  a  bottle  may  be  filled  with  ordinary 
tincture  of  green  soap  (tincture  sapo  viridis)  or  any  other  required  prepara- 
tion, i3urehased  in  quantity  or  made  up  as  desired.    Fig.  117  shows  the  use  of 


Fig.     118.       A    convenient    wall-fixture    for    liquid    soap.       Slight    upward    pressure    on    the    metal    stem    at 
the     bottom     causes     the     soap    to    flow     into     the     open    hand. 

the  drop  bottle.  A  still  more  convenient  arrangement  is  the  stationary  holder- 
for  liquid  soap,  fastened  just  above  the. washstand.  Fig.  118  shows  a  good 
pattern.  Slight  upward  pressure  against  the  projecting  stem  at  the  bottom 
causes  the  liquid  soap  to  flow  into  the  hand. 

Some  liquid  preparation  should  be  used  entirely  for  soap.  The  ordinary 
cake  soap  is  not  effective  for  surgical  cleansing. 

Brushes.  For  cleansing  the  irregularities  about  the  fingers,  a  brush  is 
necessary.  The  ordinary  small  hand-brush  of  vegetable  fiber  with  a  plain 
back  (Fig.  116,  e),  does  very  well.  Such  brushes  are  cheap  and  will  stand 
boiling  and  are  effective  as  long  as  the  fiber  portion  is  uniformly  stiff.  When 
a  brush  becomes  too  soft  from  repeated  l)oiring,  it  should  be  thrown  aAvay  or 


PREPARATIONS    FOR    EXAMINATION 


145 


laid  aside  to  be  used  on  surfaces  where  a  softer  brush  is  required,  such  as  the 
abdominal  surface  or  genitals  of  patient  being  prepared  for  operation. 

A  brush  used  in  scrubl)ing  the  hands  after  examining  an  infected  or  doubt- 
ful case,  must  be  boiled  before  being  used  again.  It  is  convenient  to  have 
several  brushes  boiled  and  kept  in  a  jar  ready  for  use.  They  may  be  kept  dry 
or  in  an  antiseptic  solution. 

Lubricant.  A  drop  or  two  of  liquid  soap  on  the  wet  fingers  or  glove 
makes  a  most  satisfactory  lubricant.  The  smallest  ciuantity  lubricates  thor- 
oughly and  is  in  a  measure  antiseptic  and  is  easily  removed.  The  author  does 
not  find  glycerine  satisfactory.  Unless  used  in  such  large  quantity  as  to  be 
inconvenient,  it  does  not  lubricate  Avell. 

In  the  absence  of  liquid  soap,  any  clean  unirritating  ointment  will  do. 
When  an  ointment  is  used,  it  is  well  to  have  it  put  up  in  a  compressible  tube 
(Fig  116,  h),  for  then  the  unused  part  is  kept  sterile. 


Fig.     119.       Patient    arranged    for    abdominal     examination    in    bed. 


USE  OF  RUBBER  GLOVES 

The  author  wishes  to  call  attention  to  the  routine  use  of  rubber  gloves  in 
examination  and  office  treatment,  particularly  in  cases  where  any  infection  is 
present  or  suspected. 

For  ordinary  office  Avork,  it  is  convenient  to  put  them  on  dry.  When  a 
small  amount  of  boric  acid  powder  or  talcum  powder  is  dusted  into  each  glove, 
it  slips  on  easily.    The  glove-covered  hands  are  then  put  through  the  regular 


146 


GYNECOLOGIC   EXAMINATION    METHODS 


washing  with  liquid  soap  and  water.  After  the  examination,  the  gloves  are 
slipped  off  and  thrown  into  a  basin  for  subsequent  boiling.  Thus  the  infective 
material  is  kept  away  from  the  washstand  as  well  as  from  the  hands.  After 
the  office  work  is  finished,  water  is  poured  into  the  basin  of  soiled  gloves  and 
they  are  boiled  for  ten  minutes.  It  is  well  to  have  a  towel  in  the  basin  to  pro- 
tect the  gloves  from  injury  by  direct  contact  with  the  hot  metal  bottom  and 


Fig.  120.  Patient  arranged  for  vaginal  examination  in  bed.  In  this  and  the  two  succeeding 
photographs,  the  sheet  has  been  pushed  aside  to  show  the  necessary  relations.  As  a  rule  the  ex- 
amination   can    be    conducted    under    the    sheet    without    any    exposure    of    the    genitals. 


sides.  After  the  sterilization,  the  gloves  are  taken  out,  cleansed  in  water  to 
remove  all  foreign  particles  adhering  to  them,  dried  on  a  clean  towel  (being 
turned  inside  out  often  enough  to  secure  good  drying) ,  dusted  inside  and  out 
with  a  drying  powder,  wrapped  in  a  clean  towel,  and  laid  away  for  subsequent 
use.     When  there  is  an  examination  or  treatment  requiring  sterile  hands,  a 


PEEPARATIONS  FOR  EXAMINATION 


147 


pair  of  the  rubber  gloves  is  wrapped  in  a  small  towel  and  dropped  into  the 
water  on  top  of  the  instruments,  to  be  boiled  with  them. 

Two  or  three  pairs  of  rubber  gloves,  kept  ready  for  use,  constitute  one  of 
the  best  investments  the  practitioner  can  make,  for  the  following  reasons: 

1.  They  protect  the  hands  from  syphilitic  or  other  infection  through  some 
unnoticed  crack  or  abrasion, 

2.  They  prevent  disagreeable  odors  clinging  to  the  hands,  as  otherwise 
happens  in  vaginal  examination  in  cases  of  advanced  uterine  cancer  and  in  all 
rectal  examinations. 

3.  Tliey  do  away  with  the  severe  scrubbing  of  the  fingers  and  hands,  which 
is  otherwise  necessary  after  each  examination  of  treatment  of  a  patient  with 
any  form  of  infection.  This  frequent  severe  scrubbing  keeps  the  skin  rough 
and  in  bad  condition. 


••-ir. :  J^-atti  ammmm 


illiriliilfllilS^Min' 


Fig.  121.  Deep  bimanual  examination  with  the  patient  in  bed.  Showing  the  relations  of  the 
examining,  hand  and  arm.  The  examiner  sits  on  the  side  of  the  bed  and  the  arm  lies  between  the 
widely-separated   thighs,    so   that   the   examination   is   made   from   directly   in   front   of   the   pelvis. 


4.  Boiling  the  gloves  after  use  eliminates  all  danger  of  carrying  contami- 
nation from  one  patient  to  another  and  keeps  the  infective  material  away  from 
the  washstand  and  other  office  fixtures. 

5.  When  an  absolutely  sterile  covering  for  the  hands  is  desired,  it  is 
easily  secured  by  boiling  the  gloves  immediately  before  use. 


148 


GYNECOLOGIC   EXA^^IIXATIOX    :\IETHODS 


AVOID  rXXECESSARY  EXPOSURE 

In  all  the  steps  of  the  examination  and  in  all  examinations  and  treat- 
ments, avoid  exposing  the  patient  any  more  than  is  necessary.  Do  not  let  your 
study  of  the  clinical  and  scientific  features  of  the  case  so  preoccupy  your  mind 
that  you  neglect  this. 

The  carelessness  manifested  in  this  respect  by  some  physicians  is  ex- 
tremely reprehensible.  This  careless  disregard  of  the  natural  modesty  of  the 
patient  is  seen  both  in  private  Avork  and  in  clinic  work  but  especially  in  the 


Fig.    122.      Deep    bimanual    palpation    with    the    patient    in    bed.    showing    the    abdominal    arm    between    the 
thighs.       The     other    arm    is    partially     hidden    by    the    sheet. 


latter,  where  it  is  just  as  reprehensible  as  in  the  former.  To  the  physician 
studying  the  difficult  features  of  a  case  in  an  endeavor  to  save  the  patient's 
life  or  restore  her  to  health,  this  may  seem  a  small  matter — but  nevertheless  it 
is  an  important  one  and  should  be  thought  of.  Furthermore,  the  poor  patient, 
who  in  the  clinic  puts  herself  under  the  care  of  the  teacher  and  his  assistants, 
is  just  as  much  entitled  to  thoughtful  consideration  in  this  matter  as  the 
M-oman  in  better  financial  circumstances  who  comes  as  a  private  patient. 


PREPARATIONS   FOR   EXAiSIINATIOX 


149 


PEESERYATION  OF  SPECIMENS 

The  preservation  of  specimens  for  microscopic  examination  is  a  very  sim- 
ple procedure  and  yet  in  many  doubtful  cases,  curettings  or  cervical  polypi 
removed  or  pieces  of  tissue  passed  spontaneously,  are  thrown  away  or  kept  iii 
such  a  manner  that  they  are  not  fit  for  microscopic  examination.  Thus  is  lost 
a  valuable  aid  to  early  diagnosis,  in  conditions  where  early  diagnosis  is  im- 
portant. 


Fig.    123.      Regular    "cross-bed"    position.      The    patient    is    turned    directly    across    the    bed,    with    the    hips 
resting  on  the  edge  of  the  bed  and  each  foot  on  a   chair. 


A  good  all-around  preservative  for  these  specimens  is  alcohol  (95%).  It 
is  nearly  always  at  hand  and  it  preserves  the  specimen  indefinitely  in  good 
condition  for  microscopic  examination.  As  soon  as  possible  after  removal  and 
without  unnecessary  handling,  the  specimen  is  dropped  into  a  small  bottle  con- 
taining the  preservative  and  then  forwarded  to  the  pathologist. 

A  10%  solution  of  formol  is  another  good  preservative.  Formol,  which  is 
a  40%  solution  of  formaldehyde  gas,  is  knoAvn  also  as  formalin  and  as  formal- 
dehyde solution. 

For  particular  points  in  the  saving  and  transmission  of  curettings  for 
diagnostic  purposes,  see  previous  pa^es  (Curetment  under  Anesthesia). 


150 


GYNECOLOGIC   EXAMINATION    METHODS 


EXAMINATION  ON  BED 


When  a  patient  is  seen  at  her  home,  sick  in  bed,  the  methods  of  explora- 
tion employed  are  usually  abdominal,  vaginal,  vagino-abdominal  and,  in  some 
cases,  recto-abdominal.  A  patient  who  is  too  sick  to  come  to  the  office  for  a 
pelvic  examination,  is  usually  suffering,  not  with  a  superficial  disturbance 
that  can  be  seen  by  inspection  of  the  external  genitals  or  through  a  speculum, 
but  with  some  deep-seated  trouble,  the  nature  of  which  can  be  determined  only 
by  deep  internal  palpation.    In  such  a  case,  the  inspection  of  the  genitals  and 


Fig.  124.  Another  method  of  arranging  a  bed-patient  for  examination  of  external  genitals. 
This  is  useful  when  the  patient  is  very  sick  or  when  movement  is  painful.  The  hips  are  simply 
slipped  to   the   edge   of  the   bed   and    one   foot   placed   on  a   chair. 


the  speculum  examination  add  nothing  of  importance  to  the  information  other- 
wise obtained,  and  as  they  are  particularly  disagreeable  to  the  patient  they 
may  be  dispensed  with. 

In  such  a  case,  the  abdominal  examination  is  first  made.  The  patient  is 
directed  to  move  to  the  edge  of  the  bed  and  the  clothing  is  loosened  and 
pushed  up  and  down,  to  expose  the  abdomen,  and  the  knees  are  drawn  up  to 
relax  the  abdominal  muscles  (Fig.  119).  The  abdomen  is  then  examined  by 
the  various  methods  previously  explained. 


PREPARATIONS   FOR   EXAMINATION  151 

The  vaginal  and  vagino-abdoniinal  examinations,  Avith  deep  bimanual 
palpation,  may  be  conveniently  and  satisfactorily  conducted  with  but  little 
disturbance  to  the  patient  by  observing  the  following  directions,  some  of 
which  were  partially  carried  out  in  arranging  for  the  abdominal  examination : 

1.  Direct  the  patient  to  move  close  to  the  left  edge  of  the  bed.  There  is 
but  little  disturbance — she  lies  just  as  she  is  in  the  bed,  except  nearer  the  left 
edge  (or  the  right  edge,  if  the  examiner  uses  the  right  hand  for  the  internal 
palpation).  A  patient  seriously  sick,  even  with  j)eritonitis,  may  usuallj^  be 
moved  over  sufficiently  without  much  pain. 

2.  Remove  the  heavy  bed-clothing,  all  except  the  sheet  with  perhaps  a 
light  blanket,  and  have  the  patient  draw  up  both  knees  so  that  the  feet  are 
near  the  buttocks  (Fig.  120). 

3.  Sit  on  the  bed,  or  on  a  chair  placed  at  the  side  of  the  bed,  against  the 
patient's  left  foot  and  direct  the  patient  to  separate  the  knees  widely.  The 
sheet  is  then  raised  sufficiently  to  permit  the  examining  hand  (with  the  index 
and  middle  fingers  well  lubricated)  to  be  passed  between  the  patient's  thighs 
(Fig.  121) — not  under  one  thigh,  as  ordinarily  directed.  The  hand  is  carried 
to  the  perineum  and  the  examining  fingers  are  introduced  deeply  into  the 
vagina,  taking  care  to  depress  the  perineum  sufficiently  to  allow  their  intro- 
duction without  pain. 

4.  After  the  simple  vaginal  examination  is  completed,  then  the  right 
hand,  passed  under  the  sheet,  is  made  to  depress  the  abdominal  wall  into  the 
pelvis  as  in  the  regular  bimanual  examination  (Fig.  122).  In  Figs.  120  and 
121  and  122,  the  sheet  has  been  pushed  aside  in  order  to  show  the  necessary 
relations.  Ordinarily  the  entire  examination  may  be  conducted  under  the 
sheet  and  without  exposing  the  patient  in  the  least. 

The  author  calls  special  attention  to  the  details  given  above  because  he 
finds  that  their  accurate  carrying  out  aids  materially  in  securing  needed  in- 
formation in  deep-seated  pelvic  troubles.  By  following  the  directions  closely, 
the  examining  hands  and.  arms  are  made  to  occupy  practically  the  same  ad- 
vantageous relation  to  the  pelvis  as  in  the  regular  office  examination  with  the 
patient  at  the  end  of  the  table — that  is,  the  examination  is  made  from  directly 
in  front  of  the  pelvis.  The  usual  procedure  of  sitting  on  a  chair  besides  the 
bed,  with  the  examining  arm  passed  under  the  thigh  (instead  of  between  the 
thighs)  is  much  less  effective  when  deep  pelvic  palpation  is  required. 

While  the  examination  steps  above  mentioned  are  generally  the  only  ones 
required  when  the  patient  is  sick  in  bed,  there  are  some  cases  in  which  further 
examination  is  advisable.  Whenever  the  patient  complains  of  sores  about  the 
genitals  or  of  itching  or  burning  or  profuse  discharge,  the  genitals  should  be 
inspected  in  a  good  light.  Ijikewise  in  any  case  in  which  it  is  thought  that 
additional  information  of  value  may  be  obtained  by  the  speculum  examina- 
tion, that  procedure  should  be  carried  out. 

For  the  inspection  of  the  external  genitals  and  for  the  speculum  examina- 


152  GYNECOLOGIC    EXAMINATION    :METH0DS 

tion,  the  patient  may  be  turned  across  the  bed  with  the  hips  near  the  edge  and 
each  foot  resting  on  a  chair  (Fig.  123).  This  is  often  referred  to  as  the 
'^ cross-bed"  position.  If  movement  of  the  patient  to  this  extent  is  likely-  to 
cause  pain,  she  may  be  simply  turned  slightly  and  one  foot  placed  on  a  chair 
while  the  other  foot  rests  on  the  bed,  as  shown  in  Fig.  124. 

NON-GYNECOLOGIC  EXAMINATION  METHODS 
IN  GYNECOLOGIC  CASES 

The  physician  must  consider  the  whole  patient.  His  work  is  to  ascer- 
tain AA'hat  is  troubling  the  patient — in  whatever  part  of  the  body  the  disease 
may  be  located  or  Avhatever  organ  or  organs  may  be  affected.  Tt  is  not  enough 
to  find  one  well-marked  disease.  All  the  important  troubles  present,  both 
organic  and  functional,  should  be  found,  for  then  only  is  the  physician  in  a 
position  to  .judge  accurately  as  to  how  far  each  disease  is  responsible  for  the 
patient's  disability  and  what  the  line  of  treatment  should  include  and  what 
the  result  will  probably  be. 

To  do  this  the  physician  must  employ,  in  gynecologic  cases,  various 
methods  of  examination  which  belong  to  other  departments  of  medicine,  and 
the  detailed  consideration  of  which  would  be  out  of  place  here.  The  author 
will  simply  call  attention  here  to  the  classes  of  patients  with  pelvic  symptoms 
in  which  such  extragynecologic  examinations  are  especially  required  in  the 
course  of  diagnosis  or  treatment.  The  examination  methods  to  which  the 
author  wishes  to  call  attention  are,  aside  from  the  usual  physical  examination 
of  the  chest,  as  follows : 

Examination  of  Urine. 
Blood  Examination. 
Sputum  Examination. 

Examination  of  .the  Xervous  .System. 

EXAMINATION  OF  URINE  IN  GYNECOLOGIC  CASES 

The  examination  of  the  urine  gives  important  information  as  to  the  metab- 
olism of  the  body  and  as  to  the  condition  of  the  most  important  excretory 
organs.  In  the  following  cases  it  is  especially  important  that  the  urine  be 
examined. 

1.  When  the  patient  is  seriously  sick  from  any  cause.  In  such  a  patient  it 
is  important  to  know  the  state  of  the  body  metabolism  and  excretion. 

2.  AVhen  there  are  bladder  or  kidney  or  ureteral  symptoms.  Do  not  treat 
the  patient  for  weeks  or  months  for  frequent  painful  urination  or  pains  in 
the  kidney  region,  without  examining  the  urine  to  see  whether  or  not  there  is 
a  local  lesion.  And  when  there  is  trouble  in  the  urinary  tract,  make  frequent 
examinations  that  you  may  keep  posted  as  to  the  improvement. 


BLOOD    EXAMINATION  153 

3.  When  the  patient  is  to  undergo  anesthesia,  either  for  operation  or  exam- 
ination. The  discovery  of  diabetes  niellitns  or  chronic  interstitial  nephritis  is 
made  with  much  more  satisfaction  to  yourself  and  much  better  prognosis  to 
the  patient  before  anesthesia  than  afterward,  when  the  patient  may  be  in 
diabetic  coma  or  uremic  convulsions.  Again,  in  the  milder  cases,  it  is  not 
pleasant  to  be  obliged  to  date  the  patient's  persistent  nephritis  from  your 
operation  or  anesthesia,  when  in  all  probability  it  was  there  before,  but  you 
have  no  proof  of  it.  Again,  a  knowledge  of  the  patient's  kidney  function  may 
cause  you  to  postpone  the  operation  or  anesthesia  for  a  time,  until  the  tem- 
porary disability  is  overcome. 

4.  In  doubtful  cases — cases  in  ^hich  the  cause  of  the  patient's  local  symp- 
toms or  general  debility  is  not  clear.  You  wonder  why  the  patient  does  not 
pick  up  and  improve  more  rapidly  under  your  excellent  treatment.  You  are 
annoyed  by  the  patient's  reiterated  complaint  of  the  bladder  irritability  or 
the  loin-pain  or  the  headaches  that  come  without  reason  or  the  digestive  dis- 
turbances that  persist  without  good  and  sufficient  cause. 

There  is  a  hidden  cause.  It  may  be  in  the  urinary  tract.  It  may,  on  the 
other  hand,  be  in  the  digestive  tract  or  in  the  blood  or  in  the  nervous  system 
or  in  the  lungs.    Find  it. 

BLOOD  EXAMINATION  IX  GYXEC0L0C4IC  CASES 

The  points  in  blood  examination  which  are  helpful  in  certain  patients 
with  gynecologic  symptoms  are  the  hemoglobin  jDercentage,  the  red-cell  count, 
leucocytosis,  poikilocytosis  and  certain  special  conditions  (Widal,  Abderhaldeu, 
and  Wassermann  reaction,  malaria  Plasmodium,  iDj^ogenic  bacteria  or  other  bac- 
teria in  the  blood). 

The  classes  of  cases  or  conditions  in  which  definite  infoi-mation  on  one 
or  more  of  these  points  may  be  of  material  assistance  are  as  follows: 

Marked  Anemia. 

Acute  Conditions  of  Doubtful  Character. 
Inflammation  of  Uncertain  Progress. 
Inflammation  with  Uncertain  Resistance. 

Blood  Examination  in  Marked  Anemia 

In  gynecologic  patients  with  marked  anemia,  there  are  three  conditions 
in  which  a  blood  examination  is  especially  useful : 

1.  When  the  Cause  of  the  Anemia  Is  Not  Clear.  You  may  be  mistaken  in 
your  idea  that  the  persistent  anemia  and  increasing  weakness  is  due  to  the 
chronic  pelvic  disease.  Possibly  the  patient  has  one  of  the  various  forms  of 
pernicious  anemia.  An  examination  of  a  stained  specimen  of  the  blood  will 
tell  at  once. 

The  author  remembers  a  patient  whose  anemia  was  supposed  to  be  due 


154  GYNECOLOGIC   EXAMINATION    METHODS 

to  an  associated  chronic  malaria  and  she  was  treated  for  that  many  months, 
until  her  condition  became  desperate.  "When  the  author  saw  her,  there  Avere 
some  pelvic  symptoms  but  not  sufficient  to  account  for  the  deterioration  of 
general  health.  Being  at  a  loss  to  account  for  the  anemia  and  weakness,  and 
finding  nothing  of  special  importance  in  the  urine,  he  took  specimens  of  the 
blood.  Examination  of  these  made  the  case  clear  at  once.  There  was  an 
advanced  leukemia,  of  which  the  patient  died  within  a  few  months..  The 
pelvic  disturbance  had  nothing  to  do  with  the  serious  symptoms. 

In  a  doubtful  case,  if  not  prepared  to  make  the  blood  examinations  your- 
self, make  some  cover-glass  spread  preparations  of  the  blood,  pack  them 
securely  in  a  pill-box  or  other  suitable  container  and  mail  them  to  a  pathologist 
with  a  brief  statement  of  the  history  of  the  case. 

2.  When  Anesthesia  or  an  Operation  Is  Required.  In  a  patient  markedly 
auemic,  anesthesia  is  a  serious  matter  even  though  it  is  only  for  a  small  opera- 
tion or  simply  for  examination. 

All  the  organs  are  below  par  and  some  condition  that  would  be  a  trivial 
matter  at  other  times  might  lead  to  a  fatal  termination.  A  red-cell  count  or 
a  hemoglobin  estimate  will  give  definite  information  as  to  the  oxygen  carrying 
power  of  the  blood.  If  the  hemoglobin  is  below  30%,  the  operation  or  anes- 
thesia should  be  postponed  if  possible  until  the  patient  has  been  put  in  a  bet- 
ter condition,  by  the  administration  of  iron  and  such  other  tonics  as  are 
indicated. 

3.  When  Trying  to  Overcome  Serious  Anemia.  In  such  a  case  a  hemoglobin 
estimate  or  blood  count  at  regular  intervals  will  show  definitely  the  effect  of 
the  treatment. 

Blood  Examination  in  Acute  Conditions   of  Doubtful  Character 

There  are  several  conditions  arising  in  patients  with  pelvic  symptoms  in 
which  the  ascertaining  of  one  or  another  fact  concerning  the  blood  is  a  decided 
help  in  determining  the  cause  of  the  patient's  serious  illness. 

1.  Fever.  The  patient  has  persistent  fever  and  pelvic  disturbance,  but  the 
cause  is  not  altogether  clear.  Is  the  fever  due  to  uterine  or  pelvic  inflamma- 
tion from  puerperal  or  non-puerperal  infection,  or  is  it  due  to  typhoid  fever 
or  malaria? 

Malaria  may  usually  be  easily  excluded  by  the  administration  of  quinine, 
but  not  always.  Examination  of  the  blood,  taken  at  the  proper  time,  will  show 
almost  certainly  whether  the  trouble  is  typhoid  fever  (AVidal  reaction,  no 
leucocytosis)  or  malaria  (plasmodium,  no  leucocytosis)  or  something  else. 

The  author  recalls  two  cases  in  particular  in  which  he  felt  that  decided 
help  was  given  by  the  blood  examination.  He  was  called  to  see  a  patient  who 
had  had  a  miscarriage  several  days  before  and  during  the  past  two  days  there 
had  been  considerable  fever.  The  temperature  (forenoon)  was  101°.  Pelvic 
examination  showed  no  decided  pathologic  condition.     The  local  conditions 


BLOOD   EXAMINATION  155 

seemed  about  as  thej^  should  be  at  that  time  after  a  miscarriage.  When  the 
author  saw  her  that  night,  the  temperature  had  gone  to  lOS'^,  but  Avas  sub- 
siding. There  was  evidently  serious  trouble  and  arrangements  Avere 
made  to  clear  out  the  uterus  the  next  morning.  That  night  when  thinking 
over  the  case,  for  he  was  somewhat  puzzled  by  it,  it  occurred  to  him  that  it 
might  be  typhoid  fever,  though  no  particular  evidence  of  this  had  been 
noticed  in  the  examination,  except  a  persistent  headache  out  of  proportion  to 
the  fever.  The  next  morning  the  temperature  v/as  again  lower  and  he  felt 
safe  in  waiting  for  the  report  of  the  blood  examination  before  disturbing 
the  uterus.  A  positive  Widal  reaction  was  found  and  the  subsequent  course  of 
the  disease  showed  it  to  be  typhoid  fever,  from  which  the  patient  recovered 
^vithout  any  uterine  disturbance.  Particular  inquiry  revealed  tile  fact  that 
the  patient  had  been  feeling  "under  the  weather"  for  some  days  before  the 
miscarriage.  Possibly  the  miscarriage  was  due  to  the  beginning  typhoid  fever, 
though  of  that  the  author  is  not  certain. 

In  the  other  case  referred  to,  the  author  was  called  in  consultation  to  see 
a  young  woman  who  for  tAvo  or  three  days  had  had  fever,  running  up  to  103° 
and  101°  in  the  afternoon  but  loAver  in  the  morning.  The  patient  had  had  a 
miscarriage  a  ^Yeek  before  and  examination  showed  a  subacute  gonorrhea. 
There  was  considerable  discharge  and  gonococci  in  abundance  but  no  decided 
evidence  of  a  septic  metritis  or  of  a  periuterine  inflammatory  focus.  Because 
of  the  regularity  of  the  fever  and  the  absence  of  the  evidences  of  a  local 
lesion  sufficient  to  account  for  it,  the  author  suspected  typhoid  fever.  Blood 
examination  shoAved  no  Widal  reaction,  neither  Avas  there  a  marked  leucocy- 
tosis.  A  second  blood  examination  gave  the  same  result  except  that  there  Avas 
more  leucocytosis.  Typhoid  fcA^er  Avas  thus  excluded.  The  author  then  sent 
the  patient  to  the  hospital  on  account  of  the  pelvic  trouble  and  in  a  short 
time  there  dcA^eloped  unmistakable  signs  of  a  focus  of  pelvic  suppuration,  AA'hich 
Avas  drained  per  A'aginam  Avith  satisfactory  result.  The  pus  from  the  abscess 
shoAA'ed  a  mixed  infection,  but  principally  gonococci. 

2.  Pain.  There  is  severe  persistent  pain  in  the  pelvis  and  marked  tender- 
ness, without  much  fever.  Is  the  pain  due  to  severe  pelvic  neuralgia,  or  other 
functional  nervous  disturbance,  or  to  bleeding  from  tubal  pregnancy?  Ordi- 
narily the  differential  diagnosis  is  easily  made  by  the  symptoms  and  physical 
signs.  But  AAdien  the  blood  in  the  peritoneal  cavity  is  fluid  (no  induration) 
and  not  of  sufficient  quantity  to  seriously  affect  the  pulse,  the  pain  and  tender- 
ness (preA'enting  satisfactory  pelvic  examination)  are  about  the  only  signs 
present.    If  decided  hemorrhage  is  present,  a  leucocytosis  may  be  found. 

AVhen  the  pain  is  associated  with  fever,  a  marked  leucocytosis  (principally 
polynuclear)  points  to  some  acute  inflammatory  trouble,  such  as  salpingitis  or 
appendicitis. 

In  uncomplicated  pelvic  tuberculosis  or  tubercular  peritonitis  there  is  no 
leucocytosis. 

In  Certain  Post-operative  Conditions  leucocytosis  may  be  of  assistance  in 


156  GYNECOLOGIC   EXAMINATION    METHODS 

connection  with  the  other  symptoms.  The  patient  has  abdominal  pains  and 
there  is  marked  distention  of  the  abdomen  and  vomiting  and  persistent  failure 
to  secure  a  bowel  movement.  Is  it  gaseous  distention  of  a  sluggish  bowel  or 
intestinal  obstruction?  It  is  said  that  the  latter  condition  nearly  always  gives 
a  leucocytosis  of  20,000  Avithin  the  first  24  hours,  while  in  simple  distention 
the  leukocyte  count  is  but  little  above  normal.  If  this  observation  proves  gen- 
erally true,  it  will  be  a  most  valuable  help  in  the  early  differential  diagnosis 
in  these  Yei'y  trying  cases. 

Blood  Examination  in  Inflammation  to  Determine  if  it  is  Spreading 

Here  the  point  is  to  determine  the  presence  or  absence  of  marked  patho- 
logic leucocytosis,  and  the  important  thing  is  not  so  much  the  absolute  in- 
crease of  leukocytes  as  the  relative  increase  of  polynuclear  leukocytes.  In 
physiologic  leucocytosis,  which  takes  place  under  many  ordinary  normal 
conditions  (after  a  meal,  after  a  cold  bath,  after  exercise,  during  pregnancy, 
in  the  puerperium,  during  menstruation),  the  relative  proportion  of  60%  to 
75%  polynuclears  is  preserved.  In  the  ordinary  pathologic  leucocytosis  the 
proportion  of  polynuclear  leukocytes  runs  higher,  particularly  in  the  presence 
of  pus. 

As  a  general  proposition  it  may  be  said  that  polynuclear  leucocytosis  is 
present  wherever  there  is  acute  resistance  to  the  spread  of  intiammation  or 
irritation.  It  is  present  then  in  practically  all  ordinary  inflammatory  lesions, 
except  when  the  acute  symptoms  have  subsided  and  the  absorption  has  ceased 
(focus  is  well  walled  off)  or  where  the  inflammation  is  so  very  virulent  that 
the  body  resistance  is  overwhelmed  and  there  is  little  reaction.  It  is  absent  in 
uncomplicated  typhoid  fever,  malaria,  tuberculosis,  influenza  and  measles. 

In  the  following  cases  the  blood  examination  may  help  some  in  determin- 
ing Avhether  the  inflammation  is  seriously  spreading. 

1.  Acute  Salpingitis  (Non-puerperal).  The  patient  is  in  the  midst  of  a 
primary  attack  of  salpingitis  with  accompanying  pelvic  peritonitis,  or  there  is 
an  acute  exacerbation  of  an  old  salpingitis.  The  fever  is  running  moderately 
high  and  there  is  much  pain.  Is  it  safe  to  wait  for  the  interval  operation  to 
remove  the  diseased  structure  or  should  the  operation  be  carried  out  now  in 
the  presence  of  this  fresh  virulent  infection?  If  the  inflammation  is  sub- 
siding, the  former  plan  is  the  better.  If  the  inflammation  is  spreading  and 
threatening  a  general  peritonitis,  the  latter  plan  is  the  better. 

In  all  but  exceptional  cases,  the  ordinary  symptoms  and  examination  find- 
ings, if  carefully  worked  out  and  considered,  will  place  the  patient  decidedly 
in  one  class  or  the  other  and  with  far  more  certainty  than  will  a  blood  test. 
In  some  doubtful  cases,  however,  repeated  examination  of  the  blood  at  short 
intervals,  to  determine  whether  the  leucocytosis  is  rising  or  falling,  will  aid 
materially  in  deciding  the  question. 

2.  Puerperal  Sepsis.    Here  also  the  ordinary  examination  methods  furnish 


SPUTUM    EXAMINATION  157 

the  most  reliable  information  concerning  the  local  and  general  condition,  and 
they  must  not  be  neglected  or  slighted  in  the  false  hope  that  laboratory  tests 
will  supply  the  desired  knowledge. 

But  in  eases  that  are  still  doubtful,  in  spite  of  careful  analysis  of  the 
symptoms  and  examination  findings,  considerable  help  may  in  some  instances 
be  obtained  by  repeated  examinations  of  the  blood  at  short  intervals  to 
determine  w^hether  the  leucocytosis  is  rising  or  falling,  and  to  determine  also 
the  number  and  character  of  the  bacteria  in  the  blood  at  different  times.  The 
exact  determination  of  these  two  facts  may  give  substantial  aid,  in  excep- 
tional cases,  in  directing  treatment  and  in  prognosis. 

Blood  Examination  in  Inflammation  to  Determine  the  Vital  Resistance 

Pathologic  leucocytosis  means  resistance.  A  slight  inflammation  aw^akens 
a  slight  resistance  (slight  leucocytosis).  A  severe  inflammation  awakens  a 
strong  resistance  (marked  leucocytosis),  if  the  patient  has  the  required  vital 
force.  There  are  exceptional  cases  in  which  the  infection  is  so  very  virulent 
that  the  vital  forces  are  overw^helmed  and  offer  but  little  resistance,  but  these 
cases  are  comparatively  infrequent.  In  ordinary  acute  inflammation  of  severe 
grade,  a  good  leucocytosis  means  good  body  resistance  and  reserve  force,  and 
a  poor  leucocytosis  means  poor  body  resistance.  This  is  the  case  particularly 
^rith  inflammation  of  the  serous  membranes,  including  the  peritoneum. 

This  fact  may  be  turned  to  account  in  cases  of  advanced  general  perito- 
nitis that  are  not  seen  until  late  and  where  it  is  a  question  whether  an  opera- 
tion could  possibly  do  any  good.  A  marked  leucocytosis  means  that  there  is 
still  decided  vital  resistance  and  there  is  a  chance  of  recovery  if  nature  is 
judiciously  aided  in  the  fight. 

The  absence  of  w^ell-marked  leucocytosis,  in  the  presence  of  this  severe 
and  active  inflammation,  means  that  the  patient's  reserve  force  is  exhausted, 
and  operation  would  probably  have  no  effect  except  to  hasten  death.  In  at- 
taching importance  to  leucocytosis  in  a  patient  in  this  desperate  condition, 
be  careful  that  you  be  not  misled  by  the  leucocytosis  that  comes  ''in  articulo 
mortis."  ' 

SPUTUM  EXAMINATION  IN  GYNECOLOGIC  CASES 

The  two  points  of  importance  are  the  presence  or  absence  of  tubercle 
bacilli  and  the  presence. of  elastic  fibers,  indicating  destruction  of  lung  tissue. 

The  gynecologic  cases  in  which  sputum  examination  is  required  are 
those  presenting  the  following  conditions : 

1.  Suspected  Pelvic  Tuberculosis.  Pelvic  tuberculosis  is  nearly  always 
secondary  to  a  tubercular  focus  elsewhere  in  the  body,  and  the  most  frequent 
sites  of  the  primary  focus  are  the  lungs  and  the  intestinal  tract.  The  patient 
may  not  acknowledge  that  she  has  a  cough,  it  is  so  slight.  But  the  direction 
to  save,  in  the  bottle  that  is  given  her,  all  the  mucus  that  can  be  got  up  in 


158  GYNECOLOGIC   EXAMINATION    METHODS 

the  morning,  will  usually  bring  sufficient  for  examination,  if  there  is  any 
trouble  there. 

2.  Unwarranted  Emaciation  and  Debility.  The  patient  has  some  pelvic 
disturbance  but  not  enough  to  cause  the  poor  general  health.  "What  does 
cause  it?  Possibly  it  is  from  beginning -pulmonary  tuberculosis.  Determine 
whether  or  not  such  is  the  case. 

EXAMINATION  OF  THE  NERVOUS  SYSTEM  IN  GYNECOLOGIC  CASES 

That  portion  of  the  nervous  system  distributed  to  the  pelvis  furnishes  its 
quota  of  local  painful  disturbances  (neuralgia,  neuritis,  transferred  pains) 
and  local  paralyses,  which  must  be  taken  into  consideration  in  the  diagnosis 
and  treatment  of  pelvic  diseases. 

There  are,  in  addition,  certain  general  diseases  of  the  nervous  system 
which  cause  complaint  of  pelvic  symptoms  and  occasion  much  confusion  in 
diagnosis.    They  are  principally  four,  as  follows : 

Hysteria,  . 

Neurasthenia, 

Hypochondria, 

Melancholia. 

The  recognition  of  these  diseases  depends  of  course  on  a  knowledge  of 
the  clinical  manifestations  of  each  disease  and  a  careful  consideration  of  the 
symptoms  presented  by  the  patient.  This  differential  diagnosis  can  not  be 
taken  up  here.  It  will  suffice  to  call  attention  to  certain  classes  of  patients 
with  pelvic  symptoms  in  which  this  special  investigation  of  the  nervous  system 
should  be  carried  out.    They  are  as  follows: 

1.  Very  Nervous  Patients.  The  author  uses  the  term  ''nervous"  in  the 
ordinary  commonly-accepted  meaning  of  the  word.  The  patient  is  perturbed 
more  than  one  would  expect  under  the  circumstances.  She  may  be  simply 
frightened  or  embarrassed  or,  on  the  other  hand,  she  may  have  some  decided 
organic  disease  of  the  brain  or  nervous  system,  or  some  functional  nervous 
disturbance. 

The  patient  may  have  a  well-marked  pelvic  lesion,  but  that  does  not  cause 
the  evidences  of  an  imstable  nervous  system.    What  does? 

This  particular  ■  consideration  of  the  nervous  system  need  not  necessarily 
be  made  at  the  first  visit.  The  patient  may  be  observed  for  a  time,  and 
possibly  it  will  be  seen  that  the  nervous  manifestations  largely  disappear  as 
acquaintance  is  established.  As  long  as  the  nervous  symptoms  persist,  how- 
ever, they  constitute  an  undetermined  factor  in  the  case,  with  a  possible  bear- 
ing on  the  patient's  loss  of  health. 

2.  Pelvic  Distress  Without  Corresponding  Lesion.  The  complaint  of  a 
gynecologic  affection  for  which  no  evidence  can  be  found,  not  even  tender- 
ness, may  be  due  to  pronounced  hypochondria. 


MISCELLANEOUS   EXAMINATION    METHODS  159 

The  i^ersistent  manifestation  by  the  patient  of  a  fixed  idea  tliat  slie  has 
some  pelvic  disease,  which  in  fact  is  not  present,  may  be  due  to  beginning 
melancholia. 

On  the  other  hand  such  complaints  may  be  due  to  a  deliberate  attempt 
on  the  part  of  the  patient  to  deceive  the  physician — ^hoping  thereby  to  secure 
an  opinion  that  would  be  useful  in  a  suit  for  damages  or  for  divorce,  or  hoping 
that  the  physician  may  use  some  examination  method  or  treatment  that  would 
lead  to  an  abortion. 

EXAMINATION  FOE  DISTURBANCE  OF  THE  ENDOCRITIC 

GLAND  SYSTELI 

The  system  of  ductless  glands  bears  a  very  intimate  relation  to  the  develop- 
ment and  functioning  of  the  reproductive  organs.  It  is  this  glandular  system 
that  is  principally  at  fault  in  a  considerable  proportion  of  cases  of  amenor- 
rhea, menorrhagia,  dysmenorrhea  and  other  derangements  of  function.  This 
subject  is  such  an  important  one  that  a  special  chapter  is  given  to  it,  and 
there  (Chapter  xv)  the  diagnostic  points  are  given  along  with  the  physiologic 
and  therapeutic  data. 

MISCELLANEOUS  EXAMINATION  METHODS 

There  are  a  number  of  other  examination  methods  which  are  occasionally 
useful  in  gynecologic  cases,  particularly  the  four  below  mentioned. 

Serum  Test  for  Pregnancy. 

The  serum  test  is  useful  in  those  cases  in  which  the  ordinary  examina- 
tion signs  are  not  conclusive  for  or  against  pregnancy.  Also,  in  unmarried 
women  where  pregnancy  is  suspected  and  yet  it  is  thought  inadvisable  to  sug- 
gest a  local  examination.  An  examination  of  the  blood,  ostensibly  on  account 
of  the  poor  health,  may  give  positive  evidence  of  pregnancy. 

This  test,  brought  out  by  Abderhalden  in  1912,  is  based  upon  the  fact 
that  during  pregnancy  the  blood  contains  a  proteolytic  ferment  which  causes 
cleavage  of  placental  albumen.  The  test  is  complicated  and  requires  labora- 
tory apparatus  and  trained  supervision.  It  is  not  necessary  to  describe  here 
the  various  steps  in  the  test.  Any  one  interested  in  the  complicated  details  may 
find  an  interesting  description  of  them,  and  a  review  of  the  literature,  in 
an  article  by  Schwarz  (Interstate  Med.  Jour.,  Vol.  XX,  No.  3,  1913). 

When  carried  out  under  proper  supervision  and  checks,  the  blood  test 
shows  certainly  the  presence  or  absence  of  the  placental  ferment.  The  reac- 
tion is  present  from  the  seventh  week  of  pregnancy,  continues  during  preg- 
nancy, and  disappears  about  two  weeks  after  the  termination  of  pregnancy, 
regardless  of  the  time   (period)    of  termination.     A  positive  reaction  means 


160  GYNECOLOGIC    EXAMINATION    METHODS 

that  the  patient  has  placental  tissue  in  the  body  or  lias  had  within  two  weeks 
past. 

The  placental  tissue  may  be  in  the  uterus  or  it  may  be  in  the  tube  or 
in  some  other  extrauterine  situation.  The  fetus  may  be  living  or  dead. 
On  the  other  hand,  there  may  be  no  fetus,  only  placental  tissue.  The  reaction 
is  given  by  hydatidiform  mole,  by  chorioepithelioma  without  recent  preg- 
nancy, and  by  any  condition  giving  placental  tissue  with  its  resulting  ferment. 

If  the  above  facts  and  limitations  be  kept  in  mind,  the  test  may  be 
used  to  advantage  in  a  number  of  classes  of  cases. 

Serum  Test  for  Gonorrhea 

The  complement-fixation  test  is  useful  in  identifying  those  gonorrheal 
cases  in  which  the  gonococcus  can  not  be  demonstrated.  This  serum  reaction 
begins  about  three  weeks  after  infection  and  persists  as  long  as  there  is  an 
active  focus  of  gonococci  in  the  body.  It  becomes  helpful,  therefore,  in  that 
large  class  of  subacute  and  chronic  cases  in  Avhich  the  gonococci  have  disap- 
peared from  the  discharge.  In  these  cases  the  diagnosis,  heretofore,  has  had  to 
rest  on  the  history  and  certain  incidental  examination  findings.  In  a  consider- 
able proportion  of  these  cases  the  history  and  examination  signs  are  uncertain 
and  a  positive  diagnosis  of  the  character  of  the  inflammation  therefore  impos- 
sible. These  include  cases  of  deep-seated  pelvic  inflammation  and  also  of  dis- 
tant foci,  such,  for  example,  as  inflammation  of  joints  or  of  serous  membranes 
(endocardium,  pleura),  in  all  of  which  a  positive  diagnosis  is  required  as  a 
guide  to  most  effective  treatment.  The  diagnosis  in  these  doubtful  cases  may 
be  cleared  up  with  fair  certainty  by  the  complement-fixation  test — provided 
the  work  is  carried  out  by  one  well  trained  and  Avith  proper  laboratory  facil- 
ities and  one  familiar  with  the  various  pitfalls  to  be  avoided  in  reaching  con- 
clusions. 

The  gonococci  in  different  cases  are  not  identical  organisms,  but  may  be- 
long to  different  ' '  strains ' '  that  react  differently.  Hence  the  antigen  for  the 
test  must  be  prepared  from  many  strains,  and  even  then  may  possibly  miss  the 
strain  present  in  the  particular  case  to  be  tested.  Again,  the  results  are  not 
dependable  if  the  individual  has  had  meningitis  or  has  been  vaccinated  against 
meningitis. 

There  are  a  number  of  other  tests  such  as  the  skin  reaction,  the  injec- 
tion of  gonococcus  vaccine,  and  the  ophthalmic  reaction,  which  may  prove  of 
value,  but  they  are  still  experimental  and  uncertain.  In  the  last  few  years 
much  work  has  been  done  towards  developing  these  serum  tests  for  gonor- 
rhea. An  excellent  resume  of  the  work  to  date,  with  its  bearing  on  diagnosis 
and  treatment,  is  given  in  a  recent  contribution  by  Abraham  Sophian  (Port- 
ner-Lewis:  Genito-Urinary  Diagnosis  and  Therapy). 


MISCELLANEOUS    EXAMINATION    METHODS  161 

Tuberculin  Test 

111  cases  of  suspected  pelvic  tuberculosis,  the  tuberculin  test  may  give 
material  aid  in  reaching  a  jjositive  decision.  There  are  several  methods  of 
making  the  test.  The  tuberculin  may  be  injected  under  the  skin,  constituting 
the  subcutaneous  tuberculin  test  of  Koch.  It  may  be  worked  into  an  abrasion 
of  the  skin,  as  in  the  cutaneous  tuberculin  test  of  Von  Pirquet.  It  may  be 
combined  with  an  ointment  and  rubbed  into  the  unbroken  skin,  as  in  the  per- 
cutaneous tuberculin  test  of  Moro.  Also,  any  of  the  mucus  surfaces  may  be 
used  for  the  percutaneous  reaction.  A  solution  of  tuberculin  may  be  dropped 
into  the  eye,  constituting  the  conjunctival  test  of  Wolff-Eisner  and  Calmette. 
The  subcutaneous  test  and  the  cutaneous  test  are  the  tAvo  most  used.  The 
percutaneous  test  is  too  uncertain  and  the  conjunctival  reaction  is  too  dan- 
gerous to  the  eye. 

Significance  of  the  Reaction.  When  the  test  is  carried  out  under  proper 
precautions  the  reaction  is  specific — it  is  produced  by  tuberculosis  antibodies 
only.  It  is  essentially  a  test  for  the  antibodies  rather  than  for  the  tubercu- 
losis itself.  To  be  antibodies  there  must,  of  course,  be  a  tuberculous  focus, 
which  produces  the  toxin  that  stimulates  the  cells  to  the  production  of  anti- 
bodies. On  the  other  hand,  there  may  exceptionally  be  a  tuberculous  focus 
without  the  production  of  antibodies,  or  at  least  without  the  production  of 
antibodies  in  sufficient  quantity  to  give  a  characteristic  reaction.  This  ab- 
sence of  antibodies  may  depend  on  the  condition  of  the  lesion  itself  (quiescent, 
thoroughly  walled  off)  or  upon  some  general  condition  of  the  patient  which 
prohibits  the  usual  antibody  formation  from  the  toxin  irritation.  In  patients 
markedly  cachetic,  from  advanced  tuberculosis  or  other  disease,  the  vital 
reaction  is  often  so  sIoav  that  antibody  formation  is  interfered  with.  The  same 
result  has  been  noted  in  many  acute  infectious  diseases,  including  scarlet  fever 
and  measles. 

In  a  patient  in  fair  physical  condition  and  with  no  other  acute  disease,  a 
negative  reaction  shows  certainly  the  absence  of  tuberculosis  (except  a  com- 
pletely quiescent  focus),  while  a  positive  reaction  shows  certainly  the  pres- 
ence of  tuberculosis.  It  must  be  kept  in  mind,  however,  that  the  test  does 
not  show  the  location  of  the  tuberculous  lesion.  Simply  because  a  patient  with 
a  suspicious  lesion  in  the  pelvis  gives  a  good  tuberculin  reaction,  it  does  not 
necessarily  follow  that  the  pelvic  lesion  is  tuberculous.  The  tuberculous  lesion 
may  be  in  a  lung  or  a  kidney  or  in  the  intestinal  tract  or  it  may  be  a  bone 
lesion,  etc.  Whether  or  not  the  focus  giving  the  tuberculin  reaction  is  in  the 
suspicious  pelvic  lesion,  must  be  determined  by  other  evidence.  Some  very 
serious  mistakes  have  been  caused  by  overlooking  this  fact. 

Subcutaneous  Tuberculin  Test  (Koch).  One  to  ten  milligrams  of  tuber- 
culin is  injected  subcutaneously,  in  one  dose  or  in  several  doses  at  intervals  of 
two  or  three  days.    In  a  healthy  individual  this  produces  no  reaction.    In  an 


162  GYNECOLOGIC    EXAMINATION    METHODS 

individual  liarboriiig  tuberculosis  antibodies,  it  x>roduces  a  decided  reaction. 
The  reaction  is  general,  local  and  focal. 

The  general  reaction  is  the  one  taken  as  characteristic  of  the  subcutaneous 
test,  and  the  most  important  feature  of  this  is  the  rise  in  temperature,  which 
appears  in  twelve  to  thirty-six  hours  and  disappears  in  one  to  three  days.  The 
maximum  temperature  varies  in  different  cases  from  100  to  103,  and  is  accom- 
panied by  corresponding  subjective  symptoms — aching,  nervousness  and  gen- 
eral discomfort. 

The  local  reaction  consists  of  swelling  and  redness  at  the  site  of  the  in- 
jection— more  than  would  be  caused  by  ordinary  bacterial  contamination.  The 
focal  reaction  consists  of  increased  congestion  about  the  tubercular  focus. 
The  disturbances  from  the  focal  congestion  may  be  sufficient  to  aid  some  in 
identifying  the  location  of  the  tubercular  lesion. 

Cutaneous  Tuberculin  Test  (Von  Pirquet).  Tuberculin,  diluted  or  undi- 
luted as  preferred,  is  worked  into  the  superficial  lymph  spaces  of  a  small  area 
by  a  specially  devised  scarifier,  which  is  furnished  ^vith  the  materials  for  the 
test.  A  control  lesion  is  made  Avith  the  same  scarifier,  thoroughly  freed  from 
tuberculin.  Alcohol  precipitates  the  tuberculin  on  the  scarifier  and  hence 
should  not  be  used — the  thorough  cleansing  of  the  scarifier  being  made  with 
water. 

The  reaction  reaches  its  height  usually  in  21  hours,  and  if  positive,  indi- 
cates tuberculosis  antibodies  in  the  individual.  Cachectic  conditions  and  acute 
diseases  interfere  with  this  test  the  same  as  with  the  subcutaneous  test.  In 
suitable  subjects,  the  cutaneous  test  has  proven  very  reliable,  and  on  account 
of  the  convenience  and  slight  disturbance,  it  has  largely  displaced  the  injec- 
tion test.  All  instructive  work  on  the  diagnostic  and  therapeutic  use  of  tuber- 
culin, is  the  recent  volume  by  Pottenger  (Tuberculin  in  Diagnosis  and  Treat- 
ment). 

Wassermann  Reaction  • 

This  blood  test  for  syphilis  has  proved  exceedingly  helpful  in  many  doubt- 
ful cases,  and  has  s„erved  to  clear  up  the  diagnosis  in  many  cases  presenting  an 
obscure  and  bafiflmg  symptom-complex. 

However,  there  has  been  a  tendency  in  some  quarters  to  place  too  much 
reliance  upon  the  AYassermann  reaction  and  its  modifications.  The  diagnosis 
should  not  be  based  upon  this  test  alone  without  other  evidence,  as  there  are 
other  conditions  that  may  give  rise  to  this  reaction. 


CHAPTER  II 

GYNECOLOGIC  DIAGNOSIS 

The  diagnosis  in  any  case  is  based  upon  the  symptoms  given  by  the  patient 
and  the  signs  fonnd  on  examination.  It  should,  as  far  as  possil^le,  be  both  an 
anatomic  and  a  pathologic  diagnosis — that  is,  it  should  state  the  location  of 
the  lesion  and  the  character  of  the  pathologic  process. 

Method  of  Diagnosis 

Accurate  diagnosis  is  much  facilitated  by  a  grouping  of  diseases  under 
certain  prominent  symptoms.  This  is  the  natural  method,  the  one  that  is  fol- 
lowed unconsciously.  The  prominent  sign  or  symptom  in  the  case  brings  to 
mind  a  group  of  diseases,  and  then  by  the  consideration  of  other  ascertained 
facts,  the  diagnosis  is  narrowed  down  to  one  or  two  diseases.  This  differentia- 
tion should  be  made  as  one  proceeds  with  the  examination. 

For  example,  suppose,  during  an  examination,  a  sore  (ulcer)  is  found  on 
the  external  genitals.  Immediately  arises  the  question,  "Is  this  a  chancroidal 
ulcer  or  a  syphilitic  ulcer  or  a  tubercular  ulcer  or  a  malignant  ulcer  or  a 
simple  ulcer  f"  Endeavor  to  settle  the  question  then  and  there.  Recall  the 
facts  in  the  history  bearing  on  the  differential  diagnosis.  Notice  the  character- 
istics of  the  lesion.  Are  there,  hi  other  parts  of  the  body,  evidences  of  syphilis 
or  tuberculosis  or  malignant  disease!  Is  there  an  irritating  discharge,  that 
could  cause  a  simple  ulcer? 

Each  important  sign  must  be  thus  critically  considered,  and  the  habit  of 
doing  so  should  be  assiduously  cultivated.  In  a  few  cases  the  diagnosis  is  ap- 
parent from  a  few  prominent  facts,  but  in  most  cases,  particularly  in  deep- 
seated  and  serious  diseases,  the  diagnosis  must  be  established  by  a  critical 
analysis  of  the  mass  of  information  obtained  in  the  history  and  examination. 
It  is  this  critical  analysis,  this  testing  and  elimination  of  diseases  that  do  not 
stand  the  test,  that  makes  the  difference  between  the  careful  diagnosis  and 
the  snap  diagnosis,  between  a  real  diagnosis  and  a  guess,  between  a  reliable 
diagnostician  and  an  unreliable  one. 

This  effective  application  of  the  signs  to  the  diagnosis  should,  as  far  as 
practicable,  be  made  promptly  and  rapidly  as  they  are  encountered  in  the  ex- 
amination. Though  in  a  systematic  history  and  examination,  all  the  important 
facts  are  supposed  to  be  obtained,  yet  if  the  application  of  the  symptoms  to  the 
diagnosis  is  made  as  one  proceeds,  certain  points  of  particular  importance  in 
the  diagnosis  in  that  case  will  be  given  the  special  attention  Avhich  they  re- 

163 


164  GYNECOLOGIC   DIAGNOSIS 

quire.  Hence  the  importance  of  having  mentally  stored,  and  ready  for 
immediate  use,  the  diagnostic  significance  of  the  various  facts  brought  out  in 
the  history  and  in  the  examination. 

The  following  resume  of  the  diagnostic  significance  of  certain  signs  and 
symptoms  is  given,  not  as  a  complete  collection  of  the  diagnostic  points  in  the 
various  diseases,  but  simply  as  a  working  plan  for  the  rapid  differentiation 
of  the  more  common  gynecologic  affections  and  other  conditions  likely  to  be 
confounded  with  them.  The  rarer  diseases  and  the  less  common  diagnostic 
points  and  the  conditions  present  in  anomalous  cases,  may  be  found  in  the 
appropriate  chapters. 

POINTS  IN  THE  ABDOMINAL  EXAMINATION 

In  this  examination  the  abdomen  is,  as  already  explained,  subjected  to 
inspection,  palpation,  percussion,  and,  in  exceptional  cases,  to  auscultation 
and  mensuration. 

The  principal  points  of  diagnostic  importance  in  connection  with  the 
abdominal  examination  are,  in  the  order  in  which  they  are  encountered  in  the 
examination,  as  follows : 

Prominence  of  Abdomen, 

Movement  of  Abdominal  Wall, 

Discoloration  of  Abdomen, 

Tension  of  Abdomen,  ~ 

Tenderness  of  Abdomen, 

Mass  in  Abdomen, 

Area  of  Dullness  in  Abdomen. 

PROMINENCE  OF  THE  ABDOMEN 

Decided  prominence  of  the  abdomen  is  due  to  many  different  affections, 
which  may  be  conveniently  arranged  in  five  groups,  as  follows : 

A.  Some  Affection  of  Abdominal  "Wall ; 

B.  Something  in  Intestines; 

0.  Something  in  Peritoneal  Cavity; 

D.  Some  Enlarged  Organ; 

E.  Tumor  from  Pelvis  or  Abdomen. 

A.  Abdominal  Prominence  From  Some  Affection  of  Wall 

Obesity  (Fig.  125).  There  is  evidence  of  fat  deposit  in  other  parts  of  the 
body.  The  abdominal  wall  may  be  picked  up  as  a  thick  roll,  and  the  fingers 
made  to  almost  meet  beneath  (Figs  126,  127),  showing  that  most  of  the  prom- 
inence is  due  to  the  thickness  of  the  wall.  There  is  no  distinct  localized  mass, 
like  a  tumor  in  the  wall. 


PROMINENCE    OF    ABDOMEN 


165 


Percu-ssion  gives  resonance  all  over  the  abdomen.  Sometimes  a  distinct 
"fat  vrsLve"  may  be  obtained,  but  it  may  be  distinguished  from  a  "flnid 
wave"  by  the  expedient  shown  in  Fig.  34,  and  also  by  percnssion.     In  some 


Fig.   125.     Obesity.     The  most  prominent  feature  in  this  case  is  the  marked   Obesity — see  Fig.   128 
There   is   also   a   fibroid   tumor   of  the   uterus    and   a    small    amount    of   ascitic   fluid. 


Fig.    126.      Testing   the    thickness    of   the    Abdominal  Fig.    127.      Testing  the  thickness  of  the  Abdominal 

Wall.      First   step.  Wall.     Second  step.     The  fingers  carried  beneath  the 

wall. 


166 


GYNECOIiOGIC    DIAGNOSIS 


Fig.  129.  Obesity,  mistaken  for  ovarian  tumor. 
This  patient  vva.',  sent  to  a  hospital  for  operation  for  a 
supposed   ovarian   cyst.      (Hirst — Diseases   of    Women.) 


Pig.  128.  Obesity.  Patient  standing.  Same 
patient  as  shown  in  Fig.  125.  Notice  t'.ie  thick 
roll  of  subcutaneous  fat  that  drops  down  below 
the    general    contour   of  the   abdomen. 


Fig. 


130.      Obesity,   mistaken   for   pregnancy  by 
patient.       (Williams — Obstetrics.) 


PROMINENCE    OF    ABDOMEN 


167 


cases,  when  the  patient  stands,  a  distinct  roll  of  fat  drops  below  the  general 
abdominal  contour,  as  shown  in  Fig.  128. 

Fig.  129  shows  a  case  of  obesity  mistaken  for  ovarian  tumor  and  sent  to 
a  hospital  for  operation.  Fig.  130  shows  a  case  of  obesity  which  was  mistaken 
for  pregnancy. 

Tumor  of  Wall.  There  is  a  distinct  mass,  which  is  superficial  and  moves 
with  the  Avail  and  is  apparently  inseparably  connected  with  it.  The  mass  may 
be  picked  up  and  the  fingers  approximated  beneath  it.     There  is  no  apparent 


Fig.     131.       A     Tumor     of     the     Abdominal     Wall.       (Montgomery — Practical     Gynecology.) 


connection  with  any  intraabdominal  organ.  There  is  dullness  on  light  per- 
cussion, but  resonance  on  deep  percussion.  Fig.  131  shows  a  tumor  of  the 
abdominal  wall. 

Inflammatory  Mass  in  Wall.  Same  as  tumor  with  evidences  of  inflamma- 
tion added — pain,  tenderness,  fever  and,  in  some  cases,  redness  and  fluctua- 
tion. 

Some  years  ago  the  author  witnessed,  as  a  visitor,  an  operation  upon  a 
supposed  strangulated  ventral  hernia.  The  patient  gave  a  history  of  a  long- 
standing swelling  some  distance  to  the  left  of  the  umbilicus.     This  suddenly 


168 


GYNECOLOGIC   DIAGNOSIS 


enlarged  and  became  painful,  the  enlargement  being  accompanied  by  abdom- 
inal pain,  vomiting,  constipation  and  evidences  of  inflammation  in  the  mass. 
The  patient  was  brought  before  a  medical  class  for  operation.  As  the  hernial 
site  was  evidently  infected,  it  was  decided  to  open  the  abdomen  elsewhere 
and  deal  with  the  intestine  through  the  clean  opening.    Accordingly  the  peri- 


Fig.    132.      A    small    Umbilical    Hernia,    with    a    relaxed    abdominal    wall.       (Hirst — Diseases    of    Women.) 


Fig.     133.      A    large    Ventral    Hernia    at    the    site    of    an    operation    scar.       (Hirst — Diseases    of     Women.) 


toneal  cavity  was  opened  by  a  median  incision.  Exploration  showed  that  the 
peritoneal  surface  of  the  abdominal  wall  on  the  affected  side  was  perfectly 
normal.  There  was  no  hernia.  The  trouble  was  an  abscess  of  the  abdominal 
wall,  probably  resulting  from  the  suppuration  of  a  tumor.    A  large  operative 


PROMINENCE    OF    ABDOMEN 


169 


opening  into  tlie  peritoneal  cavity  in  such  close  proximity  to  an  abscess,  made 
a  very  uncomfortable  state  of  aifairs  for  the  surgeon,  particularly  as  the 
abscess  was  so  large  and  so  near  the  surface  that  it  was  thought  necessary  to 
open  it  at  once.  It  was  opened  as  far  as  possible  from  the  median  incision. 
The  patient  recovered. 

Ventral  Hernia.  There  is  a  distinct  localized  protrusion,  which  is  most 
pronounced  when  standing  or  sitting,  and  diminishes  when  the  patient  lies 
down.  Coughing  makes  the  mass  prominent  and  gives  a  distinct  impulse  to  it. 
The  mass  is  resonant  on  percussion,  when  containing  intestine,  and  is  partially 


Fig. 


134.      The    Contour    of    a    Relaxed    Abdominal 
Wall,    with    the    patient    Recumbent. 


Fig.  135.  Same  patient  (Fig.  134),  Standing. 
Notice  the  marked  Projection  of  the  Relaxed  Ab- 
dominal   Wall. 


or  wholly  reducible.  AYhen  the  mass  is  reduced,  the  margin  of  the  opening 
may  be  felt.  Fig.  132  shows  an  umbilical  hernia.  Fig.  133  shows  a  ventral 
hernia  in  an  operative  scar.  When  strangulated  and  so  inilamed  as  to  pre- 
vent satisfactory  palpation,  a  ventral  hernia  may  give  much  trouble  in  diag- 
nosis, particularly  if  it  contains  only  omentum. 

Relaxation  of  Wall.    There  is  general  protrusion  of  wall  when  sitting  or 
standing,  which  largely  disappears  when  patient  lies  down,  unless  tympanites 


170 


GYNECOLOGIC   DIAGNOSIS 


Fig.     136.      Median    grooving    of    the    abdominal    wall    where    there    is    Separation    of    the    Recti    Muscles. 
The    woman    is    represented    as    lying    on    her    back.       (Webster — Diseases    of    Women.) 


Fig.  137.  Patient  with  marked  Separation  of  the  Recti  Muscles.  The  illustration  shows  the 
marked  bulging  between  the  separated  recti  as  the  head  and  chest  are  raised  from  the  table,  the 
abdominal     muscles     being    thus     made     to     contract.       (Webster — Diseases     of     Women.) 


PROMINENCE    OF    ABDOMEN 


171 


is  pronounced  (Figs.  134,  135).     On  palpation  the  walls  are  lax  and  no  abnor 
nial  mass  is  felt.    The  abdomen  is  everywhere  resonant  on  percussion. 


Fig.  138.  Patient  with  marked  Separation  of  the  Recti.  The  photograph  from  which  this 
illustration  was  made,  was  taken  as  the  upper  part  of  the  body  was  being  raised  from  the  table. 
The  physician's  fist  is  buried  in  the  gap  between  the  muscles,  which  are  contracting.  In  this  case 
there  was  pronounced  pendulous  abdomen.  As  the  patient  lay  relaxed  on  her  back,  the  distance 
between  the  muscles  at  the  level  of  the  umbilicus  measured  five  and  one-half  inches.  (Webster — 
Diseases   of    Wo  me  71.) 


Fig.  139.  Tympanites,  mistaken  for  pregnancy  by  the  patient.  The  small  figure  in  the  upper  corner 
shows  the  internal  condition  as  determined  by  the  bimanual  examination,  the  uterus  being  of  normal  size. 
(IJdgar — Practice  of  Obstetrics.) 


172 


GYNECOLOGIC   DIAGNOSIS 


Separation  of  Recti  Muscles.  The  recti  muscles  are  ordinarily  held  firmly 
together  by  the  junction  of  the  sheath  of  one  side  with  that  of  the  other  side, 
forming  a  strong  fibrous  sejDtum  in  the  median  line.  In  some  cases  of  abdom- 
inal distention  from  pregnancy  or  a  tumor,  the  tissue  between  the  recti  muscles 
is  greatly  stretched  laterally  and  remains  so.  This  gives  a  wide  Aveak  place 
between  the  recti  muscles,  in  which  the  tissues  are  lax  and  thin  (Fig.  136). 
When  the  patient  raises  her  head  and  shoulders  from  the  pillow,  or  otherwise 
makes  strong  intraabdominal  pressure,  there  is  bulging  of  this  weak  portion 
of  the  wall  between  the  recti  (Fig.  137).  In  such  a  case,  the  hand  may  be 
sunk  deeply  into  the  abdomen  between  the  separated  recti  muscles  (Fig.  138). 

B.  Abdominal  Prominence  From  Something  in  Intestines 

Gas  (tympanites).  This  may  cause  marked  prominence  when  associated 
with  relaxation  of  abdominal  wall.     There  is  no  distinct  mass  felt  on  palpa- 


Fig.   140.     Ascites.     A  moderate  amount   of  fluid  in  a   relaxed   abdomen.      Notice  how  the   abdomen   spreads 
out   at  the  sides.      (Kelly — Operative    Gynecology.) 


tion.  Percussion  shows  hyperresonance  over  all  the  abdomen.  There  are 
usually  symptoms  indicating  gastric  or  intestinal  indigestion.  Tympanites  is 
frequently  associated  with  enteroptosis.  Fig.  139  shows  tympanites  Avhich 
the  patient  mistook  for  pregnancy. 

Fecal  Impaction.  Fecal  impaction  may  cause  localized  prominence  in 
any  part  of  the  abdomen  but  it  is  usually  situated  along  the  course  of  the 
colon.  The  diagnosis  depends  largely  on  the  exclusion  of  other  causes  of 
enlargement,  the  history  of  constipation  and  the  effect  of  treatment  directed 
toward  clearing  out  the  intestinal  tract.    Have  the  patient  take  a  purgative 


PROMINENCE    OF    ABDOMEN 


173 


Fig     141       Marked   Ascites.      Notice    the    gentle    slope    at    the    lower    and    upper    portions    of    the    abdomen. 
In  the'  case  of  a  tumor  the  rise  is  usually  much  more  abrupt.      (KeUy — Operative   Gynecology.) 


Fig  142.  Extreme  Ascites.  In  the  patient  from  which  this  photograph  was  taken,  the  abdomen 
was  so  distended  with  fluid  that  the  wall  was  raised  higher  than  the  mesentery  would  permit  the  in- 
testine to  float,  giving  dullness  about  the  umbilicus  as  well  as  elsewhere  (see  Figs.  177,  17S  .  ine 
rise  of  the  wall  from  below  is  rather  abrupt.  There  is  also  edema  of  the  wall,  as  shown  by  the  per- 
sisting groove  where  the  skirts  were   tied   about   the  waist. 


174 


GYNECOLOGIC  DIAGNOSIS 


until  free  bowel  movements  are  secured,  then  a  large  enema  and  then  retui- 
for  another  examination. 


Fig.    143.      Another   case   of   extreme   Ascites,   giving   dullness   about   tlie   umbilicus   as   well    as   in   the   flanks. 
Notice    the    markedly    pyramidal    form    of    this    abdomen.       (Hirst — Diseases    of     Women.) 


Fig.    144.      Another    case    of    extreme    Ascites,    giving    dullness    about    the    umbilicus    and    showing    a    very 
abrupt    rise    of   abdominal   wall    below.      (Hirst — Diseases   of   Women.) 


C.  Abdominal  Prominence  From  Something-  in  the  Peritoneal  Cavity 

General  Ascites.  This  may  be  slight  (Fig.  140)  or  marked  (Figs.  141,  142, 
143,  144).  In  ascites,  i.e.,  free  fluid  in  the  peritoneal  cavity,  the  abdomen  is 
inclined  to  spread  out  at  the  sides  and  flatten  at  the  top.  There  is  usually  a 
distinct  fluid  wave,  obtained  as  previously  explained  (Fig.  33),  which  may 
be  distinguished  from  a  fat  wave  as  shoA\m  in  Fig.  34.  When  the  patient  is 
turned  on  the  side  or  when  she  sits  or  stands,  the  area  of  dullness  changes, 


PROMINENCE    OF    ABDOMEN 


175 


because  the  Huid  seeks  the  lowest  part  of  the  peritoneal  cavity.  Figs.  171, 
175,  176).  Another  diagnostic  point  is  that  in  some  cases  where  there  is 
free  fluid  in  the  peritoneal  cavity,  when  the  patient  stands  there  is  decided 
protrusion  of  the  umbilicus  (Fig.  145),  which  protrusion  disappears  when  the 
patient  is  in  the  recumbent  posture. 

Encysted  Fluid  (pus  or  serum  or  blood).     A  distinctly  limited  collection 


Fiar-    145.      Extreme   Ascites.      Patient   standing.      Notice   the   protrusion   of   the    umbilicus,    which    is   pushed 
out  by  the  fluid  behind  it  as   the   patient   stands.      This   is   the   same   patient   shown   in   Fig.    142. 

of  fluid,  w^alled  off  or  encysted,  may  be  present  in  peritoneal  tuberculosis  and 
also  in  abscess  from  salpingitis  or  appendicitis.  There  may  be  considerable 
solid  exudate  associated  with  the  sAvelling,  and  also  other  evidences  of 
inflammation,  either  septic  or  tubercular.  The  diagnosis  between  the  two 
forms  of  inflammation  may  usually  be  readily  made  from  the  history  and  the 
accompanying   symptoms.     Extrauterine   pregnancy,   like   the    inflammatory 


176 


GYNECOLOGIC   DIAGNOSIS 


Fig.   146.     Contour  of  the  abdomen  in  Pregnancy,  with  patient  recumbent.      (Edgar — Practice  of  Obstetrics.) 


^<  /(///  y/    'inp}nj 


Fig.  147.  Contour  of  the  abdomen  in  a  case 
of  Distended  Bladder.  The  patient  is  in  labor. 
Notice  how  well  the  bladder  prominence  stands  out 
from  the  general  abdominal  prominence  due  to  the 
pregnant  uterus.  (Norris — American  Textbook  of 
Obstetrics.} 


Fig.  148.  Frozen  section  of  the  body  of  a  woman 
who  died  from  Rupture  of  a  Distended  Bladder. 
The  cause  of  the  retention  of  urine  was  a  retro- 
verted  uterus  four  months  pregnant.  (Norris — 
American  Textbook  of  Obstetrics,  from  Arch,  of 
Gyn.) 


PROMINENCE    OF   ABDOMEN 


177 


processes  just  mentioned,  may  present  the  evidences  of  encysted  fluid.  For 
the  points  in  differential  diagnosis,  between  extrauterine  pregnancy  and  ordi- 
nary pelvic  inflammation,  see  Chapter  xi. 

Pseudocyst  of  the  Lesser  Omentum.     Following  injuries  of  the  pancreas 


Fig.    149.      Contour   of   the   abdomen   in   a   case   of   large    Cystic    Tumor    (parovarian).      Notice   the    abrupt 
rise  of  the  abdominal  wall  at  both  the  lower  and  upper  portions.      (Kelly — Operative  Gynecology.) 


Fig.    ISO.      Contour   of   the   abdomen   in   a   case    of  large    Solid    Tumor    (uterine    fibroid).      The    irregularity, 
so   common   in   solid   tumors,    is   well    marked.      (Kelly — Operative    Gynecology.) 

or  disease  of  the  same,  there  may  be  a  collection  of  fluid  in  the  lesser  peritoneal 
cavity,  causing  prominence  of  the  abdomen  and  evidence  of  encysted  fluid. 
The  diagnosis  is  usually  made  during  the  progress  of  the  operation.     In  all 


178 


GYNECOLOGIC    DIAGNOSIS 


these  cases  of  encysted  fluid  or  solid  exudate,  there  is  dullness   over  that 
joortion  of  the  mass  lying  against  the  abdominal  wall  and  resonance  elsewhere. 

D.  Abdominal  Prominence  From  Some  Enlarged  Organ 

Uterus  Pregnant  (Fig.  146).     There  is  dullness  over  the  mass  and  reso- 
nance at  the  sides  (Fig.  167).     There  is  no  change  of  outline  of  dullness  on 


Fig.  ISl.  Another  case  of  large  Cystic  Tumor.  Here  the  tumor  (an  ovarian  cyst)  is  extremely 
large  and  the  rise  of  the  abdominal  wall  at  both  lower  and  upper  portions  is  very  abrupt.  (Bovee — 
Practice    of    Gynecology.) 


Fig.   152.     Appearance  of  the  abdomen  in   a  case  of   Extrophy   of  the   Bladder.     A   carcinoma  has   developed 
in  the  deformed  and  turned-out  bladder.      (Kelly — Oj'eratk'e   Gynecology.) 


PROMINENCE    OF    ABDOMEN 


179 


change  of  position  of  patient.    There  are  also  the  varions  signs  of  pregnancy, 
inclnding  the  fetal  heart  sounds  if  the  pregnancy  is  far  enough  advanced. 

Bladder  Distended  with  Urine.  The  retention  of  urine  to  such  an  extent 
that  the  distended  bladder  produces  a  distinct  prominence  of  the  abdomen, 
happens  occasionally  in  pregnancy  with  retrodisplacement  of  uterus  (Fig. 
148),  in  labor  (Fig.  147),  in  pelvic  tumors  compressing  the  urethra  and  in 
certain  nervous  affections.  There  is  dullness  over  the  mass  and  resonance  at 
the  sides.  There  is  usually  a  frequent  desire  to  urinate,  with  the  passage  of 
onlv  a  small  amount  of  urine.     But  there  may  be  a  constant  dribbling  of 


Fig.  153.  Contour  of  the  abdomen  in  a  case  of  Retroperitoneal  Tumor  (sarcoma).  The  project- 
ing mass  in  the  region  of  the  umbilicus  is  well  shown.  The  outline  of  the  palpable  mass  and  also  the 
area  of  dullness  are  shown  in  Fig.  187.  (Patient  of  Dr.  Flsworth  Smith,  Jr.,  to  whose  kindness  the  author 
is  indebted   for  this   photograph.) 


urine  due  to  overdistention.  If  the  bladder  be  emptied  with  a  catheter  the 
diagnosis  becomes  clear.  Use  a  long  soft-rubber  catheter,  as  the  ordinary 
female  catheter  may  be  too  short  to  reach  the  entrance  of  the  bladder,  and  if 
the  catheter  be  not  flexible  it  can  not  follow  the  devious  course  of  the  distorted 
urethra.  Patients  have  died  from  rupture  of  the  bladder  due  to  unrecognized 
overdistention  (Fig.  148). 

Spleen  Enlarged  from  chronic  malaria,  leukemia  or  other  cause. 


180  GYNECOLOGIC    DIAGNOSIS 

Liver  Enlarged  from  malignant  disease,  hypertrophic  cirrhosis  or  other 
cause. 

Gall-bladder  Enlarged  on  account  of  occlusion  of  duct  and  distention  with 
mucous  secretion  and  inflammatory  exudate.  It  sometimes  becomes  so  much 
distended  as  to  form  a  large  cystic  mass  in  the  right  side  of  the  abdomen. 

E.  Abdominal  Prominence  From  a  Tumor 

A  Tumor  Projecting  up  from  the  Pelvis  (Fig.  149).  Such  a  tumor  has  its 
point  of  attachment  in  the  pelvis,  the  free  margin  of  the  growth  extending 
upward  into  the  abdominal  cavity.  The  growth  may  be  either  cystic  or  solid. 
There  is  dullness  over  the  mass  and  resonance  at  the  sides  (Fig.  168).  There 
is  no  decided  change  of  outline  of  dullness  with  change  of  position  of  patient, 
except  where  there  is  complicating  ascites.  There  are  found  also  the  usual 
symjDtoms  caused  by  the  particular  variety  of  pelvic  tumor  present. 

The  ordinary  new  growths  that  project  up  from  the  pelvis  are : 

Fibroid  tumor  of  uterus  (Fig.  150). 

Malignant  tumor  of  uterus  (carcinoma,  sarcoma). 

Cystic  tumor  of  ovary  (ovarian  cyst,  Fig.  151). 

Cystic  tumor  of  broad  ligament  (parovarian  cyst). 

Solid  tumor  of  ovary  (fibroma,  carcinoma,  sarcoma,  papilloma). 

Solid  tumor  of  bladder  (Fig.  152). 

Solid  tumor  of  rectum. 

A  Tumor  Connected  with  some  Abdominal  Structure  (Fig.  153).  Such  a 
tumor  has  its  point  of  attachment  in  the  abdomen  with  the  free  margin  of 
the  growth  extending  toward,  and  sometimes  into,  the  pelvic  cavity.  There  is 
dullness  over  that  portion  of  the  mass  lying  against  the  abdominal  wall  and 
resonance  elsewhere,  unless  there  be  associated  ascites.  There  are  symptoms 
also  pointing  to  the  organ  affected  and  the  nature  of  the  growth. 

The  principal  tumors  that  originate  in  the  abdomen  are : 

Solid  Tumors  of  the  Cecum,  Sigmoid,  or  other  parts  of  the  Intestinal 

tract  (usually  malignant). 
Solid  Tumor  of  the  Stomach  (usually  malignant). 
Solid  Tumor  of  the  Liver  (usually  malignant). 
Solid  Tumor  of  the  Spleen. 
Solid  Tumor  of  Kidney. 
Solid  Tumor  of  Pancreas. 

Solid  Tumor  of  Eetroperitoneal  Structures  (Fig.  153). 
Cystic  Tumor  of  Kidney. 
Cystic  Tumor  of  Pancreas. 
Cystic  Tumor  of  Omentum. 
Cyst  of  ^Mesentery. 
Pseudocyst  of  lesser  Omental  cavity. 


DISCOLORATION    OF    ABDOMINAL    SURFACE  181 

MOVEMENT  OF  ABDOMINAL  WALL 

In  certain  cases  some  information  may  be  obtained  by  watching  the  move- 
ments of  the  abdominal  wall. 

In  painful  affections  within  the  abdomen,  such  as  peritonitis  or  intraperi- 
toneal hemorrhage  or  intestinal  obstruction,  the  wall  is  held  rigid  to  a  con- 
siderable extent  and  the  respiratory  movements  of  the  wall  are  very  slight. 

In  the  case  of  a  tumor  splinting  the  wall,  the  portion  of  the  wall  raised 
by  the  tumor  remains  stationary,  while  the  remainder  shows  the  respiratory 
movements. 

It  is  important  to  know  whether  or  not  a  tumor  moves  with  respiration. 
As  a  rule  a  tumor  of  an  abdominal  organ  moves  up  and  down  with  the  dia- 
phragm in  respiration,  and  this  up  and  down  movement  may  often  be  dis- 
tinctly seen  and  felt  through  the  wall  at  the  lower  margin  of  the  growth  or 
at  the  prominent  part  of  the  mass.  If  the  tumor  is  firmly  adherent  to  the 
wall,  this  movement  under  the  wall  can  not  then  take  place.  In  some 
cases  this  fact  may  be  turned  to  account  in  determining  the  presence  or 
absence  of  adhesions.    A  growth  from  the  pelvis  does  not  move  with  respiration. 

Movement  of  the  child  may  sometimes  be  plainly  indicated  in  late  preg- 
nancy by  a  prominence  moving  beneath  the  wall,  due  to  an  extremity  moving 
from  one  part  of  the  uterus  to  another  and  pushing  out  the  wall  as  it  moves. 

Occasionally  the  intermittent  contraction  of  a  pregnant  uterus  may  be 
noticed  by  its  raising  the  wall  as  it  becomes  firmer  and  more  prominent. 

Pulsation  of  the  abdominal  wall  may  be  due  to  an  aneurysm.  Not  infre- 
quently, especially  in  thin  patients,  the  pulsations  of  the  normal  aorta  are 
transmitted  to  the  overlying  wall,  either  directly  or  through  an  intervening 
tumor. 

In  some  eases  of  intestinal  obstruction  or  marked  tympanites,  a  distinct 
peristaltic  wave  may  occasionally  be  seen  to  pass  across  the  abdomen  in  the 
course  of  the  distended  bowel.    It  is  usually  accompanied  by  a  cramp-like  pain. 

DISCOLORATION  OF  ABDOMINAL  SURFACE 

Occasionally  there  is  a  well-marked  central  line  of  pigmentation,  extend- 
ing from  the  pubes  to  the  umbilicus  (Fig.  18).  This  is  usually  the  result  of  a 
previous  pregnancy. 

Dilated  Veins  at  the  lower  part  of  the  abdominal  surface,  as  a  rule,  mean 
that  there  is  some  mass  compressing  the  intrapelvic  veins. 

Edema  of  the  wall  may  be  due  to  inflammation  in  the  wall,  or  to  heart  or 
liver  or  kidney  disease. 

Striae  (Fig.  16)  from  a  former  stretching  of  the  wall,  usually  mean  a 
former  pregnancy  continuing  to  near  term,  but  they  may  come  from  any  large 
tumor  or  from  a  former  obesity  of  the  abdominal  wall.  Such  striae  are  occa- 
sionally seen  on  the  thighs  of  patients  who  have  been  stout. 


182  GYNECOLOGIC   DIAGNOSIS 

When  tlie  wall  is  relaxed,  i.e.,  has  been  overstretched  and  has  not  regained 
its  tone,  it  is  very  uneven  and  the  skin  appears  wrinkled  and  corrugated.  This 
folded  redundant  condition  is  nearly  always  present  in  decided  enteroptosis. 

The  eruption  of  secondary  syphilis  (syphilitic  roseola)  is  occasionally  of 
decided  help  in  determining  the  character  of  an  atypical  vulvar  lesion.  An 
eczema  or  other  eruption  near  the  site  of  a  proposed  operative  incision,  may 
necessitate  postponement  of  the  operation  until  the  eruption  is  cured. 

A  scar  indicates  that  there  was  at  one  time  a  burn  or  a  blister  or  an  area  of 
ulceration  of  the  wall  or  an  injury  of  the  wall  or  an  operative  incision. 

TENSION  OF  ABDOMEN 

Tension  of  the  abdominal  wall  interferes  very  much  Avith  a  thorough  pel- 
vic examination.    It  is  due  to  one  of  the  following  conditions : 

Fear  or  Timidity  or  Embarrassment,  causing  the  muscular  wall  to  be  held 
tense.  This  tension  usually  disappears  as  the  examination  progresses  and  the 
patient  sees  that  you  are  not  going  to  cause  pain.  Even  in  very  troublesome 
cases,  relaxation  of  the  wall  may  usually  be  secured  by  directing  the  patient 
to  take  a  full  breath  and  then  let  the  breath  all  out.  During  expiration,  when 
not  forced,  the  wall  relaxes  and  deep  palpation  may  be  made.  In  sinking  the 
fingers  into  a  region  or  about  a  mass  for  palpation,  proceed  gently  and  firmly 
and  steadily  toward  the  desired  point,  going  a  little  deeper  with  each  expira- 
tion. Do  not  gouge  or  jab  or  endeavor  to  reach  the  depths  of  a  region  by 
sudden  forced  movements.  These  all  invite  failure  by  causing  reflex  contrac- 
tion of  the  abdominal  muscles. 

Inflammation,  Local  or  General,  beneath  the  wall  causes  tension  of  the 
overlying  muscles.  This  tension  is  usually  both  voluntary  and  involuntary. 
The  patient  can  relax  the  wall  to  some  extent  but  not  entirely,  providing  the 
inflammation  is  acute  and  severe.  There  is  also  marked  tenderness  over  the 
aifected  area  and  other  evidences  of  an  inflammatory  affection. 

Mass,  Solid  or  Containing  Fluid.  If  lying  immediately  beneath  the  wall  this 
gives  a  sensation  of  tension  or  resistance  to  the  palpating  fingers.  In  excep- 
tional cases,  as  in  an  extra  large  tumor  or  very  marked  ascites,  the  abdomen 
may  be  so  filled  that  the  outer  abdominal  wall  is  stretched  and  tense. 

Hysteric  Contraction  of  the  muscular  wall  is  sometimes  seen.  When 
taking  place  in  an  irregular  Avay  (part  contracted  and  part  relaxed)  and  asso- 
ciated with  tympanitic  distention  and  with  marked  hyperesthesia,  it  may  cause 
the  condition  known  as  ''phantom  tumor,"  which  has  led  to  so  many  serious 
mistakes  in  abdominal  diagnosis.  The  administration  of  a  purgative  to  clear 
out  the  intestines  and  diminish  the  tympanites  and  of  some  nerve  sedative  to 
diminish  the  hyperesthesia  and  nerve  irritability,  may  remove  the  tension 
sufficiently  to  admit  of  a  satisfactory  examination.  If  not,  the  patient  should 
be  examined  under  anesthesia,  provided  the  symptoms  are  serious  enough  to 


TENDERNESS   IN    ABDOMEN 


183 


make  a  positive  diagnosis  necessaiy  at  once.  Under  anesthesia  the  tension  of 
the  abdominal  wall  disappears,  and  deep  palpation  may  be  made  in  the  affected 
region  and  the  presence  or  absence  of  an  abnormal  mass  determined. 


TENDERNESS  IN  ABDOMEN 

For  the  purpose  of  studying  the  significance  of  tenderness  in  the  abdo- 
men, it  is  convenient  to  divide  the  cavity  as  previously  explained,  into  nine 


Fig.     154.       The    Right    Lower    Abdomen.      The    organs    commonly    affected    and    the    areas    accordingly    of 
particular   interest,    are    indicated    by    the    stippling. 

regions:  the  right,  left,  and  central  portions  of  the  lower  abdomen;  the  right, 
left  and  central  portions  of  the  upper  abdomen;  the  central  portion  of  the 
abdomen  (umbilical  region);  and  the  right  and  left  lumbar  regions  (Fig.  28). 

In  any  of  these,  a  local  tenderness  takes  on  particular  significance. 

Again,  there  are  certain  diseases  that  cause  a  diffuse  tenderness,  extending 
throughout  the  whole  abdomen. 


184 


GTKECOLOGIC   DIAGNOSIS 


Fig.   155.     Indicating  the  point   to   seek   for  Ten-        Fig.  156.     Indicating  the  point  to  seek  for  Appendix 
derness  due  to  Tubal  or  Ovarian  disease  of  the  right  Tenderness, 

side. 


Fig.  157.  Palpating  for  the  Appendix  itself,  to 
determine  whether  or  not  there  is  any  appreciable 
infiltration  and  thickening  of  it.  When  thickened, 
the  appendix  is  felt  as  a  small  tender  roll,  deeply- 
placed. 


Fig.  158.  Another  method  of  palpating  the  Ap- 
pendix. Beginning  near  the  umbilicus,  the  fingers 
are  carried  in  deeply  and  then  brought  slowly  out- 
ward toward  the  anterior  superior  iliac  spine.  As 
the  appendix  passes  under  the  examining  fingers,  it 
is  felt  as  a  small  roll  between  the  fingers  and  the 
posterior   abdominal   wall. 


TENDERNESS   IN   ABDOMEN 


185 


Tenderness  in  Right  Lower  Abdomen  (Fig-.  154) 

Tubal  or  Ovarian  or  Broad  Ligament  Disease  (inflammation,  tumor,  ex- 
trauterine pregnancy).  The  tenderness  is  most  marked  low  in  the  side  near 
Poupart's  ligament  (tubo-ovarian  region,  Fig.  155).  It  does  not  ordinarily 
extend  to  the  appendix  region  though  it  may,  in  exceptional  cases,  involve 
both  regions.  A  mass  may  be  felt  on  vagino-abdominal  palpation  between  the 
uterus  and  the  pelvic  wall.  There  is  a  history  of  uterine  and  pelvic  inflamma- 
tion or  other  pelvic  disturbance. 


Fig. 


159.      Indicating  the   site   to   search   for   Tenderness    of   the   Right  Ureter.      This-  may   be   found   any- 
where from  the  point  indicated  to  some  distance  inside  the  circle,  towards  the  umbilicus. 


Appendicitis.  Tenderness  is  most  marked  at  about  the  middle  of  a  line 
draAvn  from  the  right  iliac  spine  to  the  umbilicus  (McBurney's  point,  Fig.  156). 
By  sinking  the  fingers  deeply  into  the  abdomen  near  the  umbilicus  and  then 
carrying  them  outward  toward  the  iliac  spine,  the  appendix  may  often  be  felt 
to  roll  under  the  fingers  as  a  tender  cord  (Figs.  157,  158).  There  is  usually  a 
history  of  stomach  or  bowel  disturbance  and  of  attacks  of  pain  radiating 
about  the  umbilicus  and  finally  settling  do%vn  in  the  appendix  region. 


186 


GYNECOLOGIC   DIAGNOSIS 


Some  Disease  of  the  Cecum  or  Ascending  Colon.  Inflammation,  tumor 
and  intussusception  are  the  more  common  affections  of  the  cecum.  They 
present  much  the  same  local  signs  as  mild  appendicitis.  The  tenderness  and 
the  mass  are  not  localized  to  the  appendix  region,  however,  but  extend  up 
along  the  ascending  colon. 

Ureteritis.  There  is  a  painful  point  over  the  ureter  (Fig.  159)  and  tender- 
ness extending  up  and  down  the  course  of  the  same   (Fig.  154).     There  is 


Fig.     160.      The    Left    Lower    Abdomen.       The    organs    commonly    affected    and    the    areas    accordingly    of 
particular   interest,    are    indicated    by    the    stippling. 


usually  pain  extending  from  the  kidney  along  the  ureter,   to   the  bladder. 
There  is  nearly  always  decided  tenderness  over  the  kidney  (Figs.  161,  162). 

Movable  Kidney.  A  rounded  mass  is  felt  on  deep  palpation  in  or  near 
the  appendix  region.  It  is  somewhat  tender.  It  is  movable  and  may  be  dis- 
placed upward  into  the  kidney  region.  Special  methods  for  palpating  same 
are  shown  later    (Figs.   389,  390).     There  is  a  history  of  irritable  bladder. 


TENDERNESS   IN    ABDOMEN 


187 


particularly  when  standing  or  walking.  There  may  be  pain  radiating  from 
the  kidney  region  along  the  ureter  to  the  bladder.  The  urinary  findings  will 
indicate  whether  or  not  there  is  inflammation  or  irritation  along  the  urinary 
tract. 

Kidney  Disease,  for  example,  a  tumor  or  tuberculosis  or  inflammation, 
may  cause  tenderness  extending  from  the  kidney  down  into  the  right  lower 
abdomen.  Kidney  disease  is  indicated  by  tenderness  and  enlargement  found 
in  palpation,  and  by  the  urinary  findings. 

Intestinal  Disease.  Painful  diseases  of  the  small  intestine,  either  acute  or 
chronic,  may  give  rise  to  tenderness  in  the  right  lower  abdomen. 

Tubercular  Peritonitis  and  other  forms  of  peritoneal  disease  occasion  ten- 
derness here,  when  extending  to  this  region. 


Fig.     161. 


The    point    for    Kidney    Tenderness 
Laterally. 


Fig.     162. 


The    point    for    Kidney    Tenderness 
Posteriorly. 


Nervous  Affection.  Various  organic  and  functional  nervous  diseases  cause 
marked  hypersensitiveness  of  the  abdominal  surface  and  of  the  intraabdominal 
structures.  The  pain  complained  is  out  of  proportion  to  any  obvious  sign  of 
disease.  By  palpating  over  the  abdomen  it  is  found  that  there  is  tenderness 
everywhere,  even  up  on  the  chest  walls.  Pinching  up  the  skin  may  cause 
almost  as  much  pain  as  the  pressure  on  deeper  structures.  General  observa- 
tion of  the  patient  will  show  that  she  is  nervous.  Special  examination  will 
show  evidence  of  neurasthenia,  hysteria  or  other  disease  of  the  nervous 
system. 


188 


GYNECOLOGIC   DIAGNOSIS 


Tenderness  in  Left  Lower  Abdomen  (Fig.  160) 

The  affections  that  cause  tenderness  in  the  left  lower  abdomen  are  the 
same  as  those  just  given  for  the  right  lower  abdomen,  substituting  the  sigmoid 
flexure  and  the  descending  colon  for  the  appendix,  cecum  and  ascending 
colon.  Fig.  157  shows  palpation  for  left  tubo-ovarian  tenderness  and  Fig.  158 
indicates  the  point  for  left  ureteral  tenderness. 


■i  / 


;l 


Fig.    163. 


The    Right   Upper   Abdomen.      The  site    of   the   gall-bladder,    the   area    of   particular   interest   in 
this  region,  is  indicated  by  the  letters,  G.   B. 


Tenderness  in  Central  Lower  Abdomen 

Intestinal  Disease.  There  are  many  affections  of  the  intestines  that  give 
pain  on  pressure  in  the  central  lower  abdomen,  for  example,  ordinary  enteritis, 
mucous  enteritis,  tubercular  enteritis  and  typhoid  fever.  The  tenderness  is 
widespread,  usually  extending  into  the  upper  part  of  the  abdomen.    There  are 


TENDERNESS   IN   ABDOMEN 


189 


also  the  gastro-intestiiial  symptoms  that  accompany  these  diseases  and,  in  ad- 
dition, the  symptoms  and  signs  peculiar  to  each  disease. 

Inflammation  of  Uterus.  The  tenderness  is  confined  to  the  central  part  of 
the  lower  abdomen  and  is  elicited  usually  only  by  deep  pressure.  There  are 
also  the  various  special  evidences  of  uterine  inflammation. 

Pelvic  Inflammation.  Pelvic  inflammation  in  any  form  is  likely  to  give 
rise  to  tenderness  extending  throughout  the  lower  abdomen.  Even  if  the  in- 
flammation is  confined  strictly  to  the  tube  on  one  side,  there  is  usually  some 
tenderness  on  pressure  in  the  median  line.  There  is  a  history  of  pelvic  inflam- 
mation, with  characteristic  tenderness  of  the  affected  adnexa  in  the  bimanual 
examination,  and  perhaps  also  a  distinct  mass. 


Fig.  164.  Indicating  the  site  for  Tenderness  or  a  Mass  due  to  disease  of  the  Gall-bladder.  It  may- 
be found  anywhere  from  the  point  indicated  downward  and  outward  to  the  margin  of  the  ribs  on  the 
right   side. 


Bladder  Disease.  The  tenderness  is  very  low,  just  above  the  pubes.  There 
is  a  history  of  frequent,  painful  urination.  Pressure  on  the  affected  region 
may  cause  a  desire  to  urinate.  Examination  of  the  urine  will  show  evidences 
of  bladder  or  kidney  disease. 

Tubercular  Peritonitis.  This  tenderness  is  widespread  over  the  abdomen. 
There  is  encysted  fluid  or  a  mass  of  exudate  or  general  ascites.  The  trouble 
is  usually  chronic.  There  may  be  evidence  of  tuberculosis  elsewhere  (lungs, 
intestines).  There  is  no  apparent  focus  of  ordinary  infection,  such  as  salpin- 
gitis or  appendicitis. 


190  GYNECOLOGIC    DIAGNOSIS 

Tenderness  in  Right  or  Left  Lumbar  Region 

Renal  and  Suprarenal  affections  are  the  pathologic  conditions  peculiar 
to  the  lumbar  regions,  and  the  usual  causes  of  tenderness  there.  Fig.  161  indi- 
cates the  point  in  the  lateral  lumbar  region  to  make  pressure  for  kidney  tender- 
ness, and  Fig.  162  shows  the  point  posteriorly.  In  palpating  for  a  mass  in 
the  same  region,  one  hand  may  be  placed  behind  and  the  other  in  front  so  as 
to  catch  the  structure  betAveen  the  palpating  fingers. 

Tenderness  in  Right  Upper  Abdomen  (Fig.  163) 

Diseases  of  the  Gall-bladder  or  of  the  Liver  are  the  common  causes  of 
tenderness  in  the  right  upper  abdomen,  the  usual  condition  being  cholelithiasis 
or  hepatitis  or  tumor  of  the  liver.  Fig.  164  indicates  the  point  to  seek  for 
gall-bladder  tenderness.  It  may  be  found  anywhere  from  the  point  indicated 
by  the  finger  outward  to  the  costal  margin.  Occasionally  an  affection  of  the 
pyloric  end  of  the  stomach  or  of  the  duodenum  or  of  the  hepatic  flexure  of  the 
colon  or  of  the  right  kidney,  causes  tenderness  extending  well  into  the  right 
upper  abdomen.  But  in  practically  all  these  conditions  the  tenderness  may 
be  traced  out  of  this  region  and  for  a  considerable  distance  along  the  organ 
affected. 

Tenderness   in   Left   Upper   Abdomen 

Diseases  of  the  spleen  or  of  the  splenic  flexure  of  the  colon  or  of  the 
cardiac  end  of  the  stomach  or  of  the  left  kidney  or  suprarenal  capsule,  ai^e 
the  usual  causes  of  tenderness  in  the  left  upper  abdomen.  The  left  hypo- 
chondriac region  is  the  area  for  splenic  tenderness.  The  dragging  pain  from 
an  enlarged  spleen  is  usually  referred  by  the  patient  to  this  area. 

Tenderness  in  Central  Upper  Abdomen 

Tenderness  in  this  region  is  usually  due  to  an  aft'eetion  of  the  stomach,  or 
of  the  liver.  In  doubtful  cases,  when  there  is  so  much  widespread  tenderness 
that  there  is  uncertainty  as  to  whether  it  is  from  the  stomach  or  the  liver, 
remember  that  stomach  disease  is  often  accompanied  by  attacks  of  pain  under 
the  left  shoulder-blade  while  liver  disease  is  frequently  accompanied  by  pain 
under  the  right  shoulder-blade.  Less  frequently,  tenderness  in  the  region  is 
due  to  disease  of  the  pancreas  or  to  some  affection  of  the  peritoneum. 

Tenderness  in  Umbilical  Region 

Diseases  of  the  small  intestine  and  diseases  of  the  peritoneum  and  omentum, 
are  the  usual  causes  of  tenderness  localized  in  this  region.  In  the  lower  outer 
portions  of  the  region  the  ureters  encroach,  and  may  cause  point  tenderness  on 
one  or  both  sides  (Fig.  159). 


MASS    FELT    ON    ABDOMINAL   PALPATION  191 

Diffuse  Tenderness  Throughout  Abdomen 

The  usual  causes  of  this  are  general  peritonitis,  tubercular  peritonitis, 
gastro-enteritis,  neurasthenia  and  hysteria.  Appendicitis,  gastritis  and  many 
other  conditions  give  rise  to  tenderness  or  j^ain  which  is  diffuse  at  first,  but  it 
soon  becomes  distinctly  localized. 


MASS  FELT  ON  ABDOMINAL  PALPATION 

The  masses  of  particular  interest  in  gynecologic  diagnosis  are  those  situ- 
ated in  the  lower  abdomen.  For  exact  differential  diagnosis  these  are  pref- 
erably taken  up  later.  Consequently  here  the  author  will  simply  indicate  by 
name  the  various  masses  found.  It  must  be  kept  in  mind,  however,  that  in  addi- 
tion to  the  various  masses  that  may  originate  in  any  region,  masses  from  elsewhere 
may  be  found  in  that  region,  because  of  growth  or  displacement  or  both.  In 
Fig.  165,  the  arrows  indicate  the  usual  direction  of  growth,  or  displacement, 
of  a  tumor  of  the  various  organs  outlined. 

Mass  Felt  in  Right  Lower  Abdomen  (Fig-.  154) 

Tubal  Inflammation  (salpingitis,  pyosalpinx,  hydrosalpinx). 

Tubal  Pregnancy. 

Tubal  Tumor  (fibroma). 

Ovarian  Inflammation  (oophoritis,  ovarian  abscess,  cystic  ovary). 

Ovarian  Tumor  (cystic,  solid). 

Parovarian  Tumor  (cystic). 

Fibromyoma  of  Uterus. 

Appendiceal  Inflammation  or  Tumor. 

Tumor  of  Cecum. 

Movable  Kidney  or  Tumor  of  Kidney. 

Mass  Felt  in  Left  Lower  Abdomen  (Fig.  160) 

Here  are  found  the  same  conditions  as  described  for  the  right  side,  sub- 
stituting sigmoid  flexure  for  cecum  and  appendix. 

Mass  Felt  in  Central  Lower  Abdomen 

Pregnant  Uterus. 

Fibromyoma  of  Uterus. 

Malignant  Tumor  of  Uterus. 

Distended  Bladder  or  Tumor  of  Bladder. 

Pelvic  Inflammation  with  Exudate. 

Pelvic  Tuberculosis. 

Tubal  Pregnancy. 

Ovarian  or  Broad  Ligament  Tumoi-,  groAving  in  from  the  side. 


192 


GYNECOLOGIC   DIAGNOSIS 


Appendiceal,  Cecal,  Sigmoid  or  Kidney  Mass,  extending  in  from 

the  side. 
Occasionally,  Spleen,  Liver,  Gail-Bladder,  Stomaeh,  Pancreas  or 

Peritoneal  Masses,  extend  into  this  region. 

Mass  Felt  in  Right  Upper  Abdomen  (Fig-.  163) 

Enlarged  Liver. 
Enlarged  Gall-bladder. 
Tumor  of  Liver. 


^^• 


Fig.  165.  Showing  the  Direction  of  Growth  of  Tumors  of  various  Abdominal  and  Pelvic  organs.  In 
practically  all  cases,  the  direction  of  enlargement  is  toward  the  umbilical  region.  (Kelly — Operative 
Gynecology.) 


Abscess  of  Liver. 

Tumor  of  Pyloric  End  of  Stomach. 

Tumor  of  Duodenum. 

Tumor  of  Hepatic  Flexure  of  Colon. 

Tumor  of  Kidney. 

Abscess  of  Kidney. 

Tuberculosis  of  Kidney. 


MASS    FELT    ON    ABDOMINAL    PALPATION 


193 


Fig.    166.      Indicating   the    Area    of    Dullness    due    to    moderate    Distention    of    the    Bladder. 


Fig.  167.  Indicating  the  Area  of  Dullness  from  a  large  Mass  of  regular  outline  springing  from 
the  Center  of  the  Pelvis,  for  example  the  pregnant  uterus.  The  dotted  line  shows  the  upper  limit  of 
the   mass   as    determined    by   palpation. 


194 


GYNECOLOOIC  DIAGNOSIS 


Mass  Felt  in  Left  Upper  Abdomen 

Enlarged  Spleen. 

Tumor  of  Spleen. 

Abscess  of  Spleen. 

Tunior  of  Cardiac  End  of  Stomach. 

Tumor  of  Splenic  Flexure  of  Colon. 

Tumor  of  Kidney. 

Abscess  of  Kidney. 

Tuberculosis  of  Kidney. 


Fig.  168.  Indicating  the  Area  of  Dullness  from  a  Central  Pelvic  Mass  which  has  enlarged  to 
such  an  extent  that  it  nearly  fills  the  abdomen.  Notice  that  the  corona  of  resonance,  surmounting  the 
area  of  dullness,  is  symmetrical  on  the  two  sides.  If  the  mass  were  lateral,  for  example,  an  ovarian  or 
parovarian  tumor,  the  area  of  resonance  would  be  decidedly  less  on  the  side  of  the  tumor  than  on  the 
opposite  side. 


Mass  Felt  in  Central  Upper  Abdomen 

Tumor  of  Stomach. 

Tumor  of  Left  Lobe  of  Liver. 

Fecal  Impaction  in  Transverse  Colon. 

Tumor  of  Transverse  Colon. 

Tumor  of  Duodenum, 

Tumor  of  Pancreas. 


AEEA   OF   DULLNESS   IN   ABDOMEN 


195 


AREA  OF  DULLNESS  IN  ABDOMEN 

An  area  of  dullness  in  the  abdomen  indicates  that  something'  solid  or  fluid 
is  lying  against  the  abdominal  wall,  pushing  the  intestines  away  or  flatten- 
ing out  the  intestine  between  the  mass  and  the  wall.  When  an  area  of  dull- 
ness is  found  in  percussing  over  the  abdomen,  the  first  thing  to  do  is  to 
ascertain  its  exact  outline.  The  getting  of  the  shape  of  the  area  clearly  in 
mind  is  much  facilitated  by  outlining  it,  wholly  or  partially,  with  a  lead 
pencil  or  other  marker.  This  outlining  of  the  area  shows  what  region  or 
regions  it  is  situated  in,  and  also  shows  whether  or  not  it  is  of  such  position 
and  size  and  shape  as  would  be  likely  to  be  caused  by  the  enlargement  of  any 
adjacent  organ.  In  some  cases  the  employment  of  both  superficial  and  deep 
percussion  may  aid  some  in  differential  diagnosis. 


-7 


Fig.   169. 


Indicating  the  region  for   Dullness  from 
Enlarged  Liver. 


Fig.    170.      Indicating  the  region  for  Dullness   from 
Enlarged    Spleen. 


Then  determine  if  the  area  of  dullness  can  be  shifted  by  pressure — by 
attempting  to  push  about  any  mass  that  may  be  in  the  abdomen. 

Then  determine  if  the  outline  of  the  dullness  changes  with  the  position 
of  the  patient.  For  example,  mark  out  the  area  with  the  patient  lying  on 
the  back,  then  have  her  turn  on  one  side  and  mark  it  in  that  position.  Then 
have  the  patient  stand,  if  she  is  able,  and  mark  the  outline  of  the  dullness 
in  that  position.  This  is  of  much  importance  in  the  diagnosis  of  free  fluid  in 
the  peritoneal  cavity. 

An  area  of  dullness  Avhere  there  should  be  resonance  may  be  due  to  any 
of  the  following  conditions : — 

An  enlarged  organ — for  example,  the  bladder  distended  with  urine  (Fig. 


196 


GYNECOLOGIC   DIAGNOSIS 


166),  a  pregnant  uterus  or  other  median  mass  (Figs.  167,  168),  the  liver  en- 
larged from  various  causes  (Fig.  169)  or  the  spleen  enlarged' from  various 
causes  (Fig.  170).     The  dullness  extends  to  the  region  normally  occupied  by 


Fig.    171.      Showing  tlie   Area  of  Dullness  in   moder- 
ate Ascites,   with  the  patient  b'ing  on   her  back. 


Fig.  172.  Showing  the  reason  for  the  disposi- 
tion of  the  Dull  and  Resonant  Areas  in  a  case 
of  moderate  Ascites.  (Butler — Diagnostics  of  In- 
ternal   Medicine.) 


Fig.  173.  Indicating  the  relation  of  the  Dull 
and  Resonant  Areas  in  the  case  of  a  Tumor  occupy- 
ing the  central  lower  abdomen.  (Butler — Diag- 
nostics   of   Internal   Medicine.) 


Fig.  174.  Ascites.  Representing  the  patient 
turned  on  one  side.  The  fluid  gravitates  to  the  under 
side,  leaving  the  upper  fiank  resonant.  (Butler — • 
Diagnostics  of  Internal  Medicine.) 


the  organ.  It  has  about  the  shape  to  be  expected  in  symmetrical  or  asym- 
metrical enlargement  of  the  organ  in  question.  There  are  other  evidences  of 
disease  of  that  organ.    There  is  nothing  else  found  to  account  for  the  dullness. 


AREA    OF    DULLNESS    IN    ABD0:MEN 


197 


Each  of  these  points  should   be   considered,  when  endeavoring  to   ascertain 
wliether  or  not  a  mass  is  due  to  enlargement  of  some  particular  organ. 

Free  Fluid  in  Peritoneal  Cavity  (Ascites).  In  this  condition  the  fluid  of 
course  seeks  the  lowest  part  of  the  peritoneal  cavity,  being  drawn  there  by 
gravity,  and  the  upper  margin  of  the  fluid,  represented  by  the  upper  margin 
of  the  area  of  dullness,  is  approximately  horizontal.  As  the  patient  changes 
position,  the  fluid  changes  its  relative  position,  to  conform  to  the  law  just 
given — hence  the  change  in  the  outline  of  the  area  of  dullness,  which  is  so 
characteristic  in  these  cases.  To  illustrate  the  application  of  this  law,  take  a 
case  of  moderate  ascites.  With  the  patient  on  her  back  the  dullness  would 
be  as  represented  by  the  dark  area  in  Fig.  171,  with  a  corona  of  resonance 


Fig.    175.      Indicating  the   Area   of   Dullness   in    a   case   of   moderate   Ascites,   with   the   patient   turned   on   the 

left  side. 


about  the  umbilicus,  which  is  the  highest  point.  Fig.  172,  which  represents  a 
cross  section  of  the  body  in  such  a  case,  explains  the  cause  of  the  dull  and  re- 
sonant areas.  Fig.  173  shows  the  contrasting  condition  produced  by  a  tumor, 
and  the  area  of  surface  dullness  produced  by  the  same  is  indicated  in  Fig. 
167.  When  the  patient  with  ascites  turns  on  her  side,  the  fluid  shifts  as 
indicated  in  Fig.  174  and  the  area  of  dullness  changes  as  shown  in  Fig.  175, 
the  upper  flank  becoming  resonant.  When  the  patient  stands,  the  fluid  again 
shifts,  seeking  the  lowest  part,  and  the  outline  of  dullness  changes  to  that 
shown  in  Fig.  176.  Notice  that  in  alb  positions  of  the  patient,  the  fluid  occupies 
the  loAvest  part  of  the  peritoneal  cavity,  and  the  upper  margin  of  the  fluid 


198 


GYNECOLOGIC   DIAGNOSIS 


is  approximately  horizontal.  Of  course  the  height  of  the  area  of  dullness 
varies  in  different  cases  depending  on  the  amount  of  fluid  in  the  cavity. 
The  illustrations  already  referred  to  indicate  the  dullness  in  the  cases  of 
ascites  of  moderate  severity.  If  there  is  only  a  small  amount  of  fluid  in  the 
cavity,  there  may  be  only  a  small  area  of  dullness  appreciable  in  each  flank, 
as  the  patient  is  lying  on  her  back,  "When  the  patient  turns  on  the  side,  the 
area  of  dullness  increases  appreciably  in  the  lower  side  and  disappears  entirely 
in  the  upper  flank.  When  the  patient  stands,  there  may  be  a  small  area  of 
dullness  in  lower  abdomen  just  above  the  pubes,  or  there  may  be  no  dullness 
appreciable  anywhere  in  the  abdomen,  because  the  amount  of  fluid  is  so  small 
that  it  is  all  concealed  in  the  depth  of  the  pelvic  portion  of  the  peritoneal 
cavity.     On  the  other  hand,  in  exceptional  cases  the  amount   of  fluid  is  so 


Fig.   176.     Indicating  the  Area  of  Dullness  in  moderate  Ascites,  with  the  patient  standing. 


great  that  it  fills  the  peritoneal  cavity  and  raises  the  abdominal  wall  above 
the  intestines  (higher  than  the  mesentery  will  permit  the  intestines  to  float), 
giving  dullness  about  the  umbilicus  as  well  as  elsewhere.  This  does  away 
with  the  corona  of  resonance  about  the  umbilicus,  which  is  so  characteristic  a 
feature  of  ordinary  ascites. 

Fig,  142  shows  a  patient  sent  to  the  author  with  a  supposed  ovarian  cyst. 
The  general  appearance  was  very  much  like  that  t)f  a  cyst  distending  the  abdo- 
men. The  area  about  the  umbilicus  was  dull,  excluding  ordinary  ascites.  In 
percussing  carefully  over  the  whole  abdomen,  however,  the  author  found  an 
area  of  resonance  in  the  left  upper  abdomen.     Fig.  177  shows  the  outline  of 


AREA   OF   DULLNESS   IN   ABDOMEN 


199 


this  area  when  the  patient  was  lying  on  her  back.  Fig.  178  shows  the  outline 
of  the  area  of  resonance  when  the  patient  was  standing.  A  comparison  of 
these  two  areas  (Fig.  179)  showed  that  there  was  decided  variation  in  the 
area  of  dullness  with  the  change  of  position,  without  any  important  change 
in  the  general  shape  of  the  abdomen,  a  condition  that  could  be  caused  only  by 
free  fluid  in  the  peritoneal  cavity.  As  the  patient  stood,  there  was  distinct 
bulging  of  the  umbilicus  (Fig.  145)  and  distinct  fluctuation  through  the  thin 
umbilicus.  There  was  present  also  edema  of  the  abdominal  wall.  On  vaginal 
examination,  no  tumor  was  felt  in  the  pelvis.     These  signs  were  considered 


Fig.   177.     A  case  of  Extreme  Ascites.     Same  patient  as  shown  in  Fig.  142.     Showing  the  Area  of  Dullness 
when  the  patient  is   on  her  Back.     The  light  area  is  all  that  is  resonant. 


sufficient  to  exclude  ovarian  cyst,  and  the  author  sent  the  patient  back  to  her 
physician  with  a  diagnosis  of  ascites.  As  there  was  no  decided  kidney  disease 
or  heart  lesion,  the  marked  ascites  was  supposed  to  be  of  hepatic  origin,  which 
diagnosis  was  confirmed  by  the  woman's  death  from  sudden  gastric  hemor- 
rhage and  by  the  partial  postmortem  examination,  the  details  of  which  were 
kindly  given  the  author  by  her  physician. 

Figs.  143  and  144  show  other  cases  in  which  the  amount  of  ascitic  fluid 
was  so  great  that  the  abdominal  wall  was  raised  above  the  intestines,  and  the 
corona  of  resonance  about  the  umbilicus  was  consequently  absent, 


200 


GYNECOLOGIC    DIAGNOSIS 


Again,  ascites  may  be  associated  with  an  abdominal  tumor,  either  as  a 
complication  or  from  some  intercurrent  disease.  In  either  case,  the  association 
of  the  two  is  indicated  by  the  outline  of  the  area  of  dullness  with  the  patient 
in  ditferent  positions.  Fig.  125  shows  a  patient  presenting  obesity  and  a 
fibroid  tumor  and  moderate  ascites.  The  obesity  was  very  apparent  on 
inspection.  On  palpating,  to  determine  if  there  were  any  further  causes  for 
the  prominent  abdomen,  the  author  found  that  there  was  a  distinct  mass 
extending  upward  from  the  pelvis  into  the  central  abdomen.  Xothing  more 
was  found  on  palpation,  except  considerable  tenderness  over  the  tumor.   Pass- 


Fig.  178.  Extreme  Ascites.  Area  of  Dullness  with  patient  Standing.  Same  patient  as  shown  in  Fig. 
177.  Notice  the  marked  change  in  the  resonant  area.  The  upper  limit  of  the  dullness  is  now  almost  hori- 
zontal.    The  former  marks  have  not  been  completely  removed. 


ing  to  percussion  of  the  abdomen,  with  the  patient  lying  on  her  back  there  was 
dullness  over  the  mass  extending,  in  the  median  line,  to  a  short  distance 
above  the  umbilicus  and  extending  symmetrically  to  each  side.  In  trying  to 
determine  accurately  the  area  of  dullness  in  the  left  side,  the  author  found 
that  it  extended  horizontally  along  the  flank  as  shown  in  Fig.  180.  Percus- 
sion in  the  right  flank  showed  a])out  the  same  area  of  dullness  there.  The 
patient  was  then  directed  to  stand  and  percussion  was  again  employed.   When 


AREA    OF    DULLNESS    IX    ABDOMEN 


201 


standing,  the  area  of  dullness  was  as  shown  in  Fig.  181.  A  comparison  of 
these  two  outlines  (Fig.  182)  makes  it  plain  that  there  was  an  unchanging 
area  of  dullness  (due  to  the  tumor)  and  a  changing  area  of  dullness,  due  to 
free  fluid  in  the  peritoneal  cayity  (ascites). 

Encysted  Fluid.     This  may  l^e  serum  or  ordinary  pus  or  tubercular  pus. 


Fig.  179.  Extreme  Ascites.  Same  patient  as  shown  in  Fig.  177.  The  Two  Resonant  Areas  contrasted. 
The  area  enclosed  by  the  solid  line  is  resonant  when  the  patient  is  on  her  back,  while  all  elsewhere  is  dull 
on  percussion.  The  area  enclosed  by  the  dotted  line  is  resonant  when  the  patient  stands,  while  all  elsewhere 
is  dull.     The   change   of   outline   of  the  dullness   on   change  of   posture   is  clearly   marked.  * 


There  is  dullness  over  the  mass  and  resonance  elsewhere  (Figs.  183,  184). 
There  is  no  change  in  the  outline  of  the  dullness  on  change  of  position  of  the 
patient,  such  as  occurs  with  free  fluid. 

A  rather  rare  condition  of  special  interest  coming  under  this  category  is 
the  pseudocyst  of  the  lesser  omental  cavity.  An  encysted  collection  of  fluid 
occupying  the  cavity  occasionally  appears  several  weeks  or  months  following 


202 


GTXECOLOGIC    DIAGNOSIS 


ail  abdominal  injury.  Injuries  so  resulting  are  supposed  to  have  involved 
the  pancreas,  it  being  held  that  the  collection  of  fluid  in  the  lesser  omental 
cavity  is  due  to  the  irritation  from  pancreatic  fluid,  ^vhich  found  its  way  from 
the  damaged  pancreas  into  the  cavity  mentioned.  The  small  opening  that 
leads  from  this  lesser  peritoneal  cavity  into  the  greater  peritoneal  cavity 
(foramen  of  AYinslow'),  becomes  closed  in  the  beginning  of  the  trouble  and 
the  fluid  is  confined  within  the  lesser  cavity.  As  this  cavity  lies  back  of  the 
intestines,  the  mass  of  encysted  fluid  is  partially  covered  by  intestinal  reso- 
nance, presenting  the  characteristic  percussion  signs  of  a  retrointestinal  mass. 
Tumor  from  the  Pelvic  Organs.  The  tumor  may  be  solid  or  cystic.  It 
may  be  situated  in  the  center  or  laterally  or  may  fill  the  whole  abdomen. 
There  is  dullness  over  that  portion  of  the  mass  lying  against  the  abdominal 


Fig.  180.  A  case  of  Ascites  and  Tumor.  Same  patient  as  shown  in  Fig.  125.  Showing  the  Area  of 
Dullness  with  patient  on  her  Back.  The  central  dullness  is  caused  by  the  tumor  and  the  lateral  dullness  by 
ascitic  fluid.     The  dullness  is  practically  the  same  on  the  two  sides. 


wall  and  resonance  elsewhere,  unless  there  is  associated  ascites.  There  is 
no  decided  change  of  outline  of  the  dullness  with  change  of  position  of  the 
patient.  The  growth  may  spring  from  the  uterus  (Fig.  185)  or  from  the 
ovary  or  broad  ligament.  The  latter  growths  are  usually  situated  well  to  one 
side  at  first  but  later  may  fill  the  whole  lower  abdomen.  Vsually  in  such  a 
growth  there  is  still  a  corona  of  resonance  surrounding  the  upper  part  of 
the  growth  and  extending  well  into  each  flank.  In  other  cases  the  tumor 
grows  into  the  flank  and  crowds  the  intestines  upward  and  into  the  opposite 
flank.  In  such  a  case  there  is  dullness  over  all  the  front  of  the  abdomen  and 
also  in  one  flank,  there  being  resonance  in  the  opposite  flank  only  (Fig.  186). 
There  is  no  change  of  the  outline  of  resonance  with  change  of  position  of  the 


AREA   OF   DULLNESS   IN   ABDOMEN 


203 


patient,  the  distinct  resonance  in  the  opposite  flank  remaining  even  when  the 
patient  is  turned  well  over  on  that  side,  provided  there  is  no  complicating 
ascites. 

Tumor  from  Some  Abdominal  Organ.  There  is  dullness  over  that  portion 
of  the  mass  lying  against  the  wall  and  resonance  elsewhere,  unless  there  is 
associated  ascites.  Such  a  tumor  may  spring  from  the  liver  or  from  the 
spleen  or  from  some  part  of  the  gastro-intestinal  track.     The  usual  sites  for 


Fig.  181.  Ascites  and  Tumor.  Area  of  Dullness  with  patient  Standing.  Same  patient  as  shown  m 
Fig.  180.  Notice  the  marked  change  in  the  upper  limit  of  the  dullness.  It  is  now  almost  horizontal.  The 
former  marks  have  not  been  completely  removed. 

tumors  in  the  digestive  track  are  the  pyloric  end  of  the  stomach,  the  cecum 
and  the  sigmoid  flexure  of  the  colon. 

Tumor  of  Some  Retrointestinal  Structure.  The  characteristic  feature  of 
retroperitoneal  masses  (either  inflammatory  masses  or  new  growths)  is  that 
there  is  intestinal  resonance  in  front  of  them.  When  the  groAvth  reaches  a 
large  size  the  intestines  are  usually  pushed  aside  over  a  considerable  area,  so 
that  a  part  of  the  palpable  tumor  mass  shows  dullness  and  a  part  shows 
intestinal  resonance.  Fig.  187  shows  such  an  abdominal  groAvth.  The  size  of 
the  palpable  tumor  is  indicated  by  the  dotted  outline  and  the  area  of  dullness 


204 


GTXECOLOGIC    DIAGNOSIS 


Fig.  182.  Ascites  and  Tumor.  Same  patient  as  shown  in  Fig.  180.  The  Two  Areas  Contrasted.  The 
solid  line  shows  the  border  of  the  dull  area  when  the  patient  is  on  her  back  and  the  dotted  line  when  she 
is  standing.  The  change  of  outline  of  the  dullness  on  change  of  posture  is  very  evident,  making  it  beyond 
doubt  that,  whatever  other  abnormal  condition  tiere  may  be  in  the  a])domen,  there  is  certainly  free  fluid. 
iN'otice  also  that  as  the  patient  stands,  the  upper  margin  of  the  dull  area  (dotted  line)  is  approximately 
horizontal. 


Fig.  183.  Indicating  the  situation  of  the  Area 
of  Dullness  due  to  a  large  Inflammatory  ^lass  or  a 
small  Tumor  arising  from  the  right  Tubo-ovarian 
region. 


Fig.  184.  Indicating  the  situation  of  the  Area 
of  Dullness  due  to  an  Inflammatory  Mass  arising 
from  the  Appendix   or   Cecum. 


AREA   OF    DULLNESS   IN   ABDOMEN 


20J 


I'ig.    H 


Indicating    the    Irregularity    and    grotesqueness    of    form    often    presented    by    the    Dull    Area    in 
Uterine  Fibromyoinata. 


Fig.  186.  Indicating  the  outline  of  the  Area  of  Dullness  in  a  case  of  large  Ovarian  Cyst  from  the 
right  side,  the  tumor  having  become  so  large  that  it  has  crowded  the  intestines  out  of  the  right  flank,  and 
its  dull  area  joins  with  that  of  the  liver.     The  left  flank  is  resonant  and  remains  so  in  all  i^ostures. 


206 


GYNECOLOGIC   DIAGNOSIS 


is  surrounded  by  the  solid  line.  Inflation  of  the  stomach  in  this  case  caused 
the  area  of  dullness  to  disappear  almost  entirely,  showing  that  the  growth 
sprung  from  some  structure  back  of  the  stomach  cavity.  A  retrointestinal 
tumor  may  spring  from  the  pancreas  or  from  the  mesenteric  glands  or  from 
the  retroperitoneal  glands  or  adjacent  structures  or  from  the  kidneys  or 
suprarenal  glands.  A  kidney  tumor  not  infrequently  forms  a  large  mass  ex- 
tending from  the  lumbar  region  towards  the  pelvis  and  the  median  line.  The 
characteristic  percussion  sign  of  a  kidney  growth,  or  other  retroperitoneal 
growth  in  that  region,  is  that  the  colon  resonance  can  be  made  out  in  front  of 
it.  "When  the  growth  is  large,  the  colon  may  be  flattened  out  by  compression 
between  the  tumor  and  the  abdominal  wall,  and  in  that  case  no  colon  resonance 


Fig.  187.  The  Area  of  Dullness  in  a  Retroperitoneal  Growth.  Same  patient  as  shown  in  Fig.  153 
(Dr.  Flsworth  Smith's  patient).  The  area  enclosed  by  the  solid  line  is  dull  on  percussion.  The  dotted  line 
shows  the  outline  of  the  growth  as  determined  by  palpation. 


would  be  obtained  in  the  ordinary  examination.  But  the  colon  resonance 
can  be  easily  brought  out  by  inflation  of  the  colon  with  air,  introduced  through 
a  rectal  tube  by  means  of  the  ordinary  double  bulb  or  an  atomizer  bulb.  This 
point  is  well  illustrated  by  the  following  ease.  Mrs.  M.  was  sent  to  the  author 
for  operation  for  a  fibroid  tumor  of  the  uterus.  There  was  a  large  mass  lying 
in  the  left  lower  abdomen,  easily  palpable  and  extending  to  the  uterus.  Super- 
ficially it  prevented  the  appearance  of  a  pediculated  subperitoneal  fibroid. 
On  deep  palpation,  however,  this  prominent  mass  was  found  to  be  connected 
with  a  deeper  mass  which  extended  up  into  the  lumbar  region.    By  manipula- 


AREA  OP   DULLNESS   IN   ABDOMEN 


207 


tion  the  whole  mass  could  be  displaced  upward  somewhat,  sufficiently  to  show 
that  its  point  of  origin  was  probably  in  the  left  lumbar  region  and  not  in  the 
pelvis.  "When  the  tumor  was  displaced  upward,  the  vaginal  and  abdominal 
fingers,  in  the  vagino-abdominal  examination,  could  be  made  to  meet  between 
the  mass  and  the  uterus,  and  no  pedicle  connecting  the  two  could  be  felt.  The 
diagnosis  then  lay  between  a  kidney  tumor  and  an  enlarged  spleen.  The 
palpable  portion  of  the  mass  did  not  have  the  characteristic  shape  of  either 
the  kidney  or  the  spleen,  but  it  approached  nearer  the  shape  of  the  spleen. 
There  were  no  kidney  symptoms.  Percussion  showed  dullness  all  over  the 
mass  (Fig.  188) — there  was  no  colon  resonance.  But  the  mass  was  more 
deeply  placed  than  an  enlarged  spleen  usually  is,  and  the  upper  end  seemed 


Fig.   188.     Indicating  the  Area  of  Dullness  in  the 
case  of  Kidney  Tumor,  before  inflation  of  the  colon. 


Fig.    189.     Indicating  the  Area  of  Dullness  in  the 
case   of  Kidney  Tumor,   after  inflation   of  the  colon. 


to  extend  directly  into  the  kidney  region.  The  colon  was  inflated  in  the 
office  examination,  and  the  colon  resonance  at  once  stood  out  well  on  percus- 
sion (Fig.  189),  demonstrating  that  the  mass  was  back  of  the  colon  and  there- 
fore probably  a  kidney  growth.  The  correctness  of  the  diagnosis  was  proved 
at  the  operation.  Fig.  190  shows  the  mass,  which  was  a  cystic  tumor  of  the 
kidney.  The  growth  was  so  large  that  it  was  necessary  to  remove  it  by  trans- 
peritoneal nephrectomy.  The  entire  absence  of  kidney  or  bladder  symptoms 
was  due  to  the  fact  that  the  left  kidney  was  totally  destroyed  and  had  not 
been  secreting,  all  the  kidney  work  being  done  by  the  right  kidney. 


208 


GTXECOI.OGIC   DIAGNOSIS 


A  rare  and  interesting  form  of  retroperitoneal  growth  is  the  retroperi- 
toneal lipoma,  ^vhich  nsually  has  its  origin  in  the  perirenal  fat. 

It  may  grow  extensively  in  A^arions  directions  and  in  some  eases  become 
so  large  that  it  fills  the  abdomen,  pushing  the  intestines  aside  or  flattening 


Fig.   190.     The    Kidney    Tumor   itself   after    removal,    in    the    case    presenting   the    signs    shown    in    Figs.    188 

and  189. 


them  out   on  its  surface.     Keynolds   reported   a   very   extensive   tumor   of   this 
kind.    He  was  able  to  collect  forty-nine  cases  from  literature. 

Tumor  or  Inflammatory  Mass  in  Abdominal  Wall.  This  may  give  rise  to 
dullness  on  superficial  percussion  or  even  on  moderately  deep  percussion.  But 
very  deep  percussion  will  show  some  resonance  all  over,  except  in  cases  Avhere 


EXAMINATION    OF    EXTERNAL    GENITALS 


209 


the  mass  is  so  extremely  large  that  the  diagnosis  is  plain  from  other  signs. 
Fig.  131  shoAvs  a  growth  situated  in  the  abdominal  wall. 

POINTS  IN  THE  EXAMINATION  OF  EXTERNAL  GENITALS 

The  appearance  of  the  external  genitals  in  the  virgin  is  shown  in  Fig. 
191.  The  same  structures  are  shown  diagrammatically  and  with  names  on 
the  parts  in  Fig.  192.  The  appearance  of  the  hymen  differs  much  in  different 
cases,  as  indicated  in  Figs.  193,  194,  195.     In  the  married  woman  the  vaginal 


^IROIN 


'C'Urcl\€tt€ 


Fig.  191.  External  Genitals  of  a  Virgin.  Photo- 
graph from  a  cadaver.  (Dickinson — American  Text- 
book  of  Obstetrics.) 


Fig.  192.  Diagrammatic  representation  of  the 
External  Genitals  of  a  X'irgin.  (Dickinson — Ameri- 
can   Textbook   of   Obstetrics.) 


opening  is  larger  and  dilatable  and  the  labia  minora  are  better  marked,  being 
much  larger  and  considerably  corrugated  (Fig.  196).  "When  the  patient  has 
had  children,  the  hymen  is  ordinarily  destroyed  and  the  vaginal  opening  is 
still  larger.  In  some  eases  when  the  labia  are  spread  apart  for  the  examina- 
tion, the  hymen  may  be  traced  out  in  its  entirety,  with  breaks  here  and  there 
from  the  tears  in  labor.  In  other  cases,  the  torn  portions  have  been  largely 
destroyed  by  pi-essure  during  the  labor  and  there  remains  only  an  occasional 


210 


GYNECOLOGIC    DIAGNOSIS 


m 


m 


M 


Mt. 


Fig.    193,   194,   195.      Showing  the  various  forms  of  Hymen.      (Dickinson — American   Textbook  of  Obstetrics.) 


Fig.    196.     External  Genitals  of  a  Married  Woman.      (Dickinson — American  Textbook  of  Obstetrics.) 


exa:\iinatiox  of  external  genitals 


211 


Fig.   197.     This  photograph  was  taken -with  the  camera  very  close  to  the  patient  and  with  the  operating 
speculum  in  place.     The  Relations  of  the  Urinary  Meatus  and  the  Labia  Minora  and  the  Vaginal  Opening 

are  well  shown. 


212 


GYNECOLOGIC   DIAGNOSIS 


tag  of  tissue  along  the  vulvo-vaginal  junction.  These  irregular  tags  of  tis- 
sue constitute  the  "carunculae  myrtif ormes. "  The  corrugated  condition  of 
the  labia  minora  is  shown  in  Fig.  197,  in  which  the  genitals  have  been  shaved 
as  for  operation.  The  relations  of  the  urethral  opening  to  the  margin  of  the 
vaginal  opening  and  to  the  labia  are  exceptionally  well  shoAvn  in  Fig.  197,  in 
which  the  operating  speculum  is  in  place.  Fig.  198  gives  a  clear  idea  of  the 
appearance  when  there  is  moderate  laceration  of  the  perineum. 


V-\\ 


•Tr 


Fig.    198.      External   Genitals   of   a   Multipara,   with   some   Perineal   Laceration.      (Dickinson — American    Text- 
book  of  Obstetrics.) 


DISCHARGE  ABOUT  EXTERNAL  GENITALS 

As  explained  in  Chapter  i,  there  is  normally  a  slight  discharge  about  the 
external  genitals,  sufficient  to  keep  the  parts  moist. 

Abnormal  discharge  may  be  only  an  increase  in  the  normal  muco-epithelial 
discharge  or  it  may  be  muco-purulent  or  purulent  or  watery  or  bloody.  The 
various  kinds  of  discharge  are  conveniently  considered  under  the  two  terms, 
leucorrhoea  and  bloody  discharge. 


EXAMINATION   OF    EXTERNAL   GENITALS  213 


Leucorrhea 


Under  this  term  the  author  includes  all  varieties  of  pathologic  discharge 
from  the  genitals,  except  discharge  containing  blood. 

Regarding  leucorrhea  due  to  extragenital  disturbances  only,  that  is 
hardly  probable,  as  the  leucorrhoea  in  itself  is  evidence  of  local  disturbance. 
There  are,  however,  certain  cases  in  which  the  functional  disturbance,  evi- 
denced by  the  leucorrhea,  is  dependent  largely  on  malnutrition  or  on  pelvic 
congestion  from  extragenital  causes.  The  mild  leucorrhea  found  in  the 
anemic  or  cachectic,  may  disappear  when  the  patient  is  put  in  good  general 
health.  Again,  in  pelvic  congestion  from  heart  disease  or  from  some  general 
cause,  there  may  be  present  a  mild  leucorrhea  which  disappears  when  the 
functional  pelvic  congestion  is  corrected.  In  this  sense,  leucorrhea  may  be 
said,  in  some  cases,  to  be  due  to  extragenital  causes  and  its  relief  to  depend 
on  treatment  of  the  same.  In  all  but  exceptional  cases,  however,  leucorrhea 
is  due  to  one  or  more  of  the  following  local  conditions : 

Inflammation  or  Ulcer  of  Vulva.  There  is  a  history  of  discharge  from 
the  vulva,  of  burning  or  itching  and  of  frequent  urination  with  perhaps  some 
pain.  Examination  of  the  external  genitals  shows  redness,  either  general  or 
localized  to  certain  areas.  There  is  tenderness  and  discharge  and  also  evi- 
dence of  the  cause.  If  the  trouble  is  an  ulcer,  it  may  be  simple,  chancroidal, 
syphilitic,  tubercular  or  malignant.  Further  examination  shows  no  discharge 
from  the  vagina  and  no  evidence  of  trouble  there. 

Acute  Vaginitis.  There  is  a  history  of  a  free  yellow  discharge  of  short 
duration,  irritation  of  vulva  and  frequent  urination  with  some  burning.  Ex- 
amination shows  a  yellow  discharge  and  redness  of  vulva.  If  gonorrheal, 
there  is  usually  involvment  of  vulvo-vaginal  glands,  also  the  discharge  shows 
gonococci.  The  vaginal  walls  are  rough  and  hot  and  tender — too  tender  to 
admit  of  satisfactory  bimanual  examination.  When  exposed  with  the  specu- 
lum, the  vaginal  walls  are  reddened,  and  there  is  not  enough  discharge  from 
the  cervix  to  account  for  the  leucorrhea. 

Chronic  Vaginitis.  This  occurs  principally  in  children.  There  has  been 
a  yellow  discharge  for  several  weeks  or  months,  with  irritation  of  the  vulva 
and  some  bladder  irritability.  Examination  shows  a  yellow  discharge  and 
some  redness  of  the  vulva,  with  more  or  less  tenderness.  The  discharge 
should  be  examined  for  gonococci.  If  the  patient  is  a  child,  no  vaginal  exam- 
ination is  made.  If  an  adult,  examination  shows  tenderness  and  chronic 
thickening  and  roughening  of  vaginal  walls,  usually  most  marked  in  the 
posterior  fornix.  Speculum  examination  shows  redness  of  the  vaginal  walls, 
either  generally  or  in  patches,  and  there  is  not  enough  discharge  from  the 
cervix  to  account  for  the  leucorrhea. 

Adhesive  Vaginitis.  This  occurs  principally  near  or  after  the  menopause. 
There  is  a  history  of  chronic  discharge,  with  irritation  of  the  vulva  and  some- 
times bladder  irritability.     On  examination  it  is  found  in  most  cases  that  the 


214  GYNECOLOGIC   DIAGNOSIS 

discharge  is  slight  and  is  sticky  or  "gluey"  in  character,  though  in  excep- 
tional eases  it  is  free  and  purulent.  In  some  cases  there  are  scratch  marks, 
resulting  from  the. patient's  attempts  to  overcome  the  pruritus.  On  vaginal 
examination,  the  vaginal  walls  are  found  adherent  in  spots,  especially  at  the 
upper  part  of  the  vagina.  If  the  adhesions  are  recent,  they  separate  easily 
with  some  bleeding.  If  the  adhesions  are  old,  they  are  firm  and  in  some  cases 
the  vagina  is  almost  obliterated  by  the  process.  When  the  walls  are  separated 
with  the  speculum,  in  the  less  advanced  cases,  irregular  spots  which  are  raw 
and  bleed  slightly  may  be  seen. 

Ulcer  of  Vagina.  This  may  be  simple,  chancroidal,  syphilitic,  tubercular 
or  malignant.  There  is  a  history  of  an  acute  or  chronic  discharge,  and  prob- 
ably also  of  other  evidences  of  the  disease  causing  the  ulceration.  Examina- 
tion shows  a  discharge  about  the  vulva  and  more  or  less  irritation  of  the 
surfaces.  When  making  the  vaginal  examination,  the  indurated  edges  or 
base  of  the  ulcer  may  be  felt.  The  speculum  exposes  the  ulcer  to  view,  and 
further  investigation  shoAvs  it  to  be  the  sufficient  cause  of  the  discharge. 

Acute  Endocervicitis.  There  is  a  history  of  a  tenacious,  stringy  discharge, 
of  recent  origin.  There  may  or  may  not  be  irritation  of  the  external  genitals. 
Vaginal  and  bimanual  examination  show  nothing  special.  Speculum  examina- 
tion shows  a  stringy  tenacious  discharge  coming  from  the  external  os.  There 
is  also  congestion  of  the  cervix  and  usually  erosion  about  the  external  os. 

Chronic  Endocervicitis.  There  has  been  a  discharge  for  a  long  time. 
Vaginal  and  bimanual  examination  shoAv  no  evidence  of  involvement  of  the 
corpus  uteri  or  the  adnexa.  Speculum  examination  shows  a  very  tenacious, 
stringy  mucopurulent  discharge  from  the  external  os,  with  more  or  less 
surrounding  erosion.  In  many  cases  there  has  been  also  severe  laceration  of 
the  cervix,  the  evidences  of  which  may  be  felt  and  seen. 

Laceration  of  Cervix.  In  these  cases,  the  discharge  is  due  not  so  much 
to  the  tear  itself  as  to  the  subsequent  eversion  and  irritation  and  chronic  in- 
flammation. The  various  appearances  presented  by  the  lacerated  cervix  are 
shown  later  in  this  chapter,  under  "Points  in  the  Speculum  Examination." 

Ulcer  of  Cervix.  Such  an  ulcer  may  be  simple,  chancroidal,  syphilitic, 
tubercular  or  malignant.  There  is  a  history  of  leucorrhea.  In  the  vaginal 
examination  the  ulcer  of  the  cervix  may  or  may  not  be  felt,  depending  on 
whether  or  not  there  is  any  induration  in  the  edges  or  base.  When  the  cervix 
is  exposed  with- the  speculum,  the  ulcer  is  seen,  presenting  a  distinctly-marked 
margin,  and  a  base  of  granulation  tissue   (epithelial  covering  entirely  lost). 

Malignant  Disease  of  Cervix.  This  may  appear  in  the  form  of  an  ulcer, 
with  indurated  margins  and  base,  or  as  a  papillary  growth  from  some  spot 
on  the  cervix  or  within  the  cervix.  For  the  various  appearances  of  beginning 
malignant  disease  of  the  cervix,  see  under  "Points  in  the  Speculum  Examina- 
tion" in  the  latter  part  of  this  chapter  and  see  also  Chapter  ix. 

Polypi  of  Cervix.     Polypi  of  the  cervix,  of  various  kinds,  may  give  rise 


EXAMINATION    OF    EXTERNAL   GENITALS  215 

to  consideralDle  leucorrhea,  though  usualh'  a  bloody  discharge  is  the  prom- 
inent feature  in  these  cases. 

Acute  Endometritis,  whether  gonorrheal  or  due  to  other  infections  follow- 
ing labor  or  miscarriage,  gives  rise  to  free  discharge.  There  is  a  history  of 
recent  labor  or  miscarriage  or  instrumentation  or  gonorrhea,  or  a  history  of 
chronic  endometritis  due  to  one  of  these  causes.  Examination  shows  a  free 
discharge,  the  character  of  which  points  to  the  cause  of  the  trouble,  as  ex- 
plained ill  Chapter  vi.  Vaginal  and  bimanual  examination  show  tenderness 
of  the  body  of  the  uterus,  but  no  tenderness  around  the  uterus,  unless  there 
is  complicating  trouble.  Speculum  examination  shows  a  free  purulent  or 
sanguino-purulent  discharge  coming  from  the  uterus. 

Chronic  Endometritis.  Hyperplasia  of  Endometrium.  There  is  a  history 
of  chronic  leucorrhea.  Examination  shows  nothing  in  the  vagina  or  cervix  to 
account  for  the  discharge.  The  body  of  the  uterus  may  be  somewhat  enlarged 
or  tender,  though  not  necessarily  so.  Through  the  speculum,  it  is  seen  that  the 
discharge  comes  from  the  uterus  and  not  from  inflammation  of  the  vaginal 
walls..  The  character  of  the  discharge  indicates  that  it  conies  largely  from 
the  endometrium  and  not  from  the  cervical  glands. 

Retrodisplacement  of  Uterus  causes  leucorrhea  by  causing  persistent 
congestion  of  the  endometrium. 

Fibroid  of  Uterus  causes  leucorrhea  by  causing  chronic  irritation  of  the 
endometrium,  both  by  direct  pressure  and  by  interference  with  its  blood 
supply. 

Cancer  of  Corpus  Uteri  causes  leucorrhea  by  the  breaking-down  of  the 
cancerous  area,  and  also  by  the  chronic  irritation  of  the  adjacent  endometrium. 

Periuterine  Disease  causes  leucorrhea  by  causing  chronic  congestion  of 
the  endometrium. 

Functional  Cong'estion  of  the  uterus  or  pelvis,  possibly  due  to  ovarian 
hyperactivity,  causes  leucorrhea  by  causing  nutritive  changes  in  the  endome- 
trium and  cervical  mucosa. 

Bloody  Discharge  From  Genitals 

Bleeding,  not  connected  with  menstruation,  may  vary  from  a  streak  of 
blood,  or  a  slight  coloring  of  a  muco-purulent  discharge,  to  a  free  flow  of 
blood.  Occasionally  there  is  a  hemorrhage  sufficiently  free  to  threaten  the 
patient's  life.  In  most  cases,  however,  the  bloody  discharge  is  slight  and 
irregular,  and  is  of  serious  import  only  because  it  may  have  a  serious  condi- 
tion for  its  cause. 

Any  of  the  following  diseases  may  cause  a  bloody  discharge  from  the 
genital  tract,  the  character  of  the  discharge  varying  from  a  muco-purulent 
discharge  only  slightly  streaked  with  blood,  to  a  profuse  flow  of  blood  and 
clots. 

All  the  conditions  mentioned  in  the  first  part  of  the  list  give  rise  also  to 


216  GYXECOLOGIC    DIAGNOSIS 

leucorrhea  and  are   mentioned  under  it.     Tlie   other   conditions   occur  with 
pregnancy  and  must  be  thouglit  of  whenever  a  bloody  discharge  is  present. 

Inflammation   or  Ulcer   of  Vulva, 
-  particularly  malignant  ulcer. 
Acute  Vaginitis. 
Chronic  Vaginitis. 
Adhesive  Vaginitis. 
Ulcer  of  Vagina. 
Acute  Endocervicitis. 
Chronic  Endocer^dcitis. 
Laceration  of  Cervix. 
Ulcer  of  Cervix. 
Cancer  of  Cervix. 
Polypi  of  Cer^dx. 
Acute  Endometritis. 
Chronic  Endometritis. 
Eetrodisplacement  of  Uterus. 
Fibroid  of  Uterus.^  ' 
Cancer  of  Corpus  Uteri. 
Periuterine  Disease. 
Functional  Congestion.  -^ 

Threatened  Miscarriage.  The  patient  may  have  missed  the  menses  only 
a  few  days  or  she  may  be  several  months  pregnant.  Threatened  miscarriage 
is  usually  accompanied  by  considerable  pelvic  pain.  In  exceptional  cases 
there  may  be  bloody  discharge  for  several  hours  or  a  day  or  two,  before  pains 
begin.  In  some  cases  by  questioning  the  patient,  it  will  be  found  that,  failing 
to  come  unwell  at  the  proper  time,  she  has  been  taking  medicine  to  ''bring  on 
the  flow"  (produce  an  abortion). 

Miscarriage.  Here  there  are  sharp  cramp-like  pains,  with  the  expulsion 
of  blood  clots  and  pieces  of  membrane  or  a  formed  fetus,  depending  on  the 
period  of  pregnancy  at  which  the  accident  happens.  Then  the  pain  sub- 
sides and  after  a  few  days  the  bloody  discharge  ceases. 

Incomplete  Miscarriage.  The  uterus  is  not  entirely  emptied  and  the  re- 
tained remnants  cause  a  persistent  bloody  discharge  for  one  or  two  weeks 
after  it  should  have  stopped,  and  there  is  also  resulting  subinvolution  of  the 
uterus.  The  blood  may  pass  as  a  muco-sanguinous  discharge  or  in  clots.  It 
may  disappear  when  the  patient  stays  in  bed,  to  reappear  when  she  gets  up. 
This  is  probably  the  most  frequent  cause  of  persistent  bleeding  in  women 
of  the  child-bearing  age.  There  is  usually  little  pain  after  the  miscarriage 
has  taken  place.  The  principal  symptom  is  the  bleeding,  with  the  resulting 
anemia  and  weakness.  If  infection  takes  place,  the  symptoms  of  sepsis  are 
added. 

Placenta  Previa.     Bleeding  from  this  cause  does  not  usually  take  place 


^ 


INFLAMMATION    OP   EXTERNAL    GENITALS 


217 


until  the  pregnancy  has  advanced  so  far  that  the  diagnosis  is  perfectly  clear. 

Laceration  of  Cervix  with  Pregnancy.  The  cervix  is  lacerated  and 
everted  and  eroded,  and  there  is  added  the  softening  and  congestion  from 
pregnancy.  There  are  no  pains  such  as  accompany  miscarriage.  There  may 
be  some  slight  pain  or  uneasiness  in  pelvis,  which  is  relieved  by  lying  down. 
The  bloody  discharge  persists,  off  and  on,  without  apparent  evidence  of 
threatened  miscarriage  or  other  intrauterine  disturbance. 

Tubal  Pregnancy.  The  rupture  of  a  tulial  pregnancy,  or  a  tubal  abortion, 
is  nearly  always  followed  in  a  few  days  by  an  irregular  bloody  discharge, 
which  may  persist  for  several  days  or  several  weeks.  In  some  cases,  pieces 
of  decidua  are  expelled  with  the  bloody  discharge.  There  are  also  the  other 
evidences  of  tubal  pregnancy  (see  Chapter  xi). 


Fig.   199.     Follicular   Vulvitis.      (A.    Martin,   after   Huguier— ^</aj   oj   Gynecology.) 


INFLAMMATION  OF  EXTERNAL  GENITALS 

Inflammation  of  the  vulva  is  due  to  the  same  causes  as  inflammation  else- 
where, namely,  irritation  and  infection.  The  most  frequent  form  of  infec- 
tion here  is  gonorrhea,  although  other  varieties  of  pus  infection  may  be  en- 
grafted on  wounds  or  abrasions. 

Cronorrheal  Vulvitis.     There   is   a   free   yellow   discharge,   with   usually 


218 


GYNECOLOGIC    DIAGNOSIS 


more  or  less  involvement  of  the  urethra  and  also  of  the  ducts  of  the  vulvo- 
vaginal glands  (Fig.  46).  There  is  no  cause  apparent  for  the  persistence  of 
a  simple  inflammation.  Microscopic  examination  of  the  discharge  shows 
gonococci. 

Simple  Vulvitis.  Occurs  most  frequently  in  children  and  is  due  to  un- 
cleanliness  of  the  parts  or  to  an  irritating  vaginal  discharge  or  to  irritating 
urine  or  to  scratching  or  other  irritation.  This  is  not  usually  as  severe  as 
gonorrheal  inflammation  and  subsides  when  the  parts  are  cleansed  fre- 
quently and  protected  from  irritation.  A  considerable  proportion  of  the  cases 
of  chronic  vulvitis  in  children  are  gonorrheal.  Consequently  the  discharge 
should  be  examined  to  determine  that  point. 


Fig.   200.     Kraurosis  Vulvae.      (Hirst — Diseases  of  Women.) 

Follicular  Vulvitis  is  characterized  by  the  inflammation  being  localized 
principally  in  the  follicles  here  and  there   (Fig.  199). 

Pruritus  Vulvae.  Itching  of  the  genitals,  from  various  causes,  leads  to 
scratching  and  consequent  inflammation.  Usually  some  cause  can  be  found 
for  the  itching.  If  not,  the  affection  is  for  the  time  being,  given  the  above 
name. 

Kraurosis  Vulvae  (Fig.  200)  is  a  peculiar  neuro-atrophic  condition  of  the 
external  genitals,  usually  preceded  by  a  long  period  of  pruritus.  The  skni 
becomes  atrophic  and  has  a  bleached  and  drawn  and  withered  appearance. 
It  is  seen  most  frequently  in  elderly  women,  and  is  usually  accompanied  by 
intense  pruritus,  as  attested  by  the  history  of  the  case  and  by  the  abrasions 
from  scratching. 


ULCER   ON    EXTERNAL    GENITALS 


219 


ULCER  ON  EXTERNAL  GENITALS 

Simple  Ulcer.  It  presents  none  of  the  characteristics  of  special  ulcers. 
There  is  some  source  of  irritation  sufficient  to  account  for  the  ulcer  and  it 
heals  quickly  under  simple  cleansing  treatment. 

Chancroidal  Ulcer  (soft  chancre).  This  is  an  angry-looking  sore  with 
sharpcut  or  undermined  edges.  It  is  painful.  The  margins  are  soft  unless 
very  old,  and  in  any  case  do  not  present  the  extensive  and  firm  induration 
found  in  the  fully  developed  syphilitic  chancre.  Usually  there  are  one  or 
more  small  sores  on  the  surfaces  that  come  in  contact  with  the  secretion  from 
the  first  sore  (Fig.  201).     There  may  be  a  history  of  suspicious  coitus  a  few 


Fig.    201.      Chancroidal   Ulcers    of   the    vulva.      (J^ovee— Practice   of   Gynecology.) 

days  previous  to  the  development  of  the  sore.  The  ulcer  persists  in  spite  of 
simple  antiseptic  remedies.  After  cauterization  with  carbolic  acid,  it  pre- 
sents healthy  granulation  and  heals  rapidly. 

Syphilitic  Ulcer.  A  syphilitic  sore  appearing  about  the  external  genitals 
may  belong  to  the  primary,  secondary  or  tertiary  stage  of  the  disease. 

(a)  Primary  Syphilitic  Ulcer  (hard  chancre).  This  appears  ten  days  or 
two  weeks  after  intercourse,  but  may  be  preceded  by  a  simple  sore  or  chan- 
croidal sore  (mixed"  infection).  It  is  not  painful  unless  irritated  or  inflamed. 
It  gradually  enlarges  and  develops  a  distinct  induration.  It  is,  a  little  later, 
accompanied  by  enlargement  of  the  inguinal  glands.  The  enlarged  glands 
are  painless,  discrete  and  non-suppurating.  There  is  only  one  such  sore.  It 
is  followed  in  one  or  two  months  by  the  secondary  manifestations. 


220 


GYNECOLOGIC    DIAGNOSIS 


(b)  Second AEY  Syphilitic  Ulcer.  These  are  usually  multiple  and  very- 
superficial,  amounting  to  little  more  than  abrasions.  They  sho^v  a  moist,  raw- 
looking  surface,  or  are  slightly  raised  whitish  areas  ("mucous  patches"). 
They  are  accompanied  by  one  or  more  of  the  various  other  secondary  mani- 
festations of  syphilis,  the  most  common  of  which  are  persistent  sore  throat, 
mucous  patches  in  the  mouth,  enlargement  of  postcervical  and  epitrochlear 
glands,  roseola  on  chest  and  abdomen,  and  loss  of  hair. 


Fig.  202.     A  Tubercular  Ulcer  of  the  vulva.      (Kelly — Operative   Gynecology.) 


(c)  Tertiary  Syphilitic  Ulcer.  This  usually  has  deep  undermined  edges. 
It  is  destructive  and  not  especially  painful,  and  is  accompanied  by  other 
evidences  of  syphilis,  such  as  ulcer  of  rectum,  gummata  along  tibia,  night 
pains,  etc.  It  yields  to  antisyphilitie  treatment,  provided  the  general  health 
is  not  too  much  depressed. 


ULCER    OX    EXTERNAL    GENITALS 


221 


Tubercular  Ulcer  (Fig.  202).  This  is  a  chronic  ulcer  with  indurated  mar- 
gins and  presenting  small  yellow  granules  in  the  base.  It  is  not  particularly 
painful,  but  is  persistent  in  spite  of  cleansing  treatment.  :\Iieroscopie  exam- 
ination of  an  excised  piece,  shows  tuberculosis. 


Fig.   203.     An     Epithelioma     of     the     right     labium. 
(Hirst — Diseases    of    Women.) 


Fig.   204.     A    beginning    Epithelioma     of    the    left 
labium  majus.    (Kelly — Operative  Gynecology.) 


Fig.   205.     An  Epithelioma  of  the  clitoris.      (Hirst- 
Diseases  of  Women.) 


222  GYNECOLOGIC   DIAGNOSIS 

Malignant  Ulcer  (Figs.  ,203,  204,  205).  This  is  a  clironic  ulcer  with  a 
considerable  area  of  induration  around  it.  It  bleeds  easily,  and  the  bleeding- 
is  not  checked  by  the  application  of  10  per  cent  copper  sulphate  solution.  The 
ulcer  persists  in  spite  of  treatment.  Microscopic  examination  of  an  excised 
piece  shows  carcinoma  or  sarcoma. 

Ulcus  Rodens  Vulvae.  This  is  chronic  and  is  irregular  in  shape,  extending 
in  various  directions  and  healing  in  others,  and  resists  treatment.  It  pre- 
sents none  of  the  pathognomonic  signs  of  chancroidal,  syphilitic,  tubercular 
or  malignant  ulcer.  The  essential  feature  of  ulcus  rodens  vulvae  is  a  chronic 
destructive  ulcer  of  the  vulva  that  can  not  properly  be  assigned  to  any  of  the 
other  classes. 


MALFORMATIONS  OF  EXTERNAL  GENITALS 

The  more  common  deviations  from  the  normal,  found  in  uninjured 
genitalia,  are  as  follows: 

Preputial  Adhesions  (Figs.  206  and  207).  The  prominent  end  of  the 
clitoris  seems  to  be  absent.  Investigating  further,  to  see  just  what  is  the 
trouble,  it  is  found  that  the  folds  of  the  labia  minora,  which  encircle  the 
clitoris,  are  agglutinated  so  that  the  glans  clitoridis  is  partially  or  entirely 
hidden. 

Labial  Adhesions.  The  labia  minora  may  be  adherent  partially  or  com- 
pletely, as  shown  in  Fig.  208. 

Imperforate  Hymen.  There  is  no  opening  into  the  vagina  and  there  has 
been  no  menstrual  flow.  There  may-  or  may  not  be  some  bulging  of  the 
imperforate  hymen.  If  there  is  much  blood  collected  back  of  the  obstruc- 
tion, fluctuation  may  be  obtained.  Fig.  209  shows  the  appearance  of  the 
vestibule  in  such  a  case.  Figs.  210  and  211  give  a  diagrammatic  representation 
of  the  conditions  internally  in  different  cases. 

Absence  of  Vagina.  Fig.  212  shows  the  condition  of  the  external  genitals 
in  a  patient  with  no  vagina. 

Double  Vagina  (Figs.  213,  214).  The  opening  of  the  second  vaginal 
canal  may  be  very  apparent  or  it  may  be  hardly  noticeable  on  cursory  inspec- 
tion. In  one  of  the  author's  cases  there  was  simply  an  unevenness,  that  at- 
tracted his  attention  almost  by  accident.  Investigating  the  slight  irregu- 
larity at  the  side  of  the  vaginal  entrance  he  found  a  slit-like  opening  leading 
into  a  second  vaginal  canal  which  was  collapsed. 

LACERATIONS  ABOUT  VULVA  AND  PERINEUM 

There  are  of  course  slight  lacerations  of  the  hymen  in  normal  coitus,  but 
the  resulting  condition  belongs  under  the  normal  appearance  of  the  genitals 
(Fig.  195).  The  same  may  be  said  of  the  usual  widening  and  relaxation  of 
the  vaginal  opening  resulting  from  labor. 


LACERATIONS    ABOUT   VULVA   AND   PERINEUM 


223 


Fig.  206.  A  case  of  Adherent  Prepuce,  the 
clitoris  being  entirely  hidden.  (Kelly — Operative 
Gynecology.) 


Fig.  207.  The  same  case,  with  the  Adhesions 
Separated  and  the  prepuce  pushed  back  and  the 
clitoris  exposed.  Notice  the  smegma  concretions 
which  had  formed  under  the  adherent  prepuce. 
(Kelly — Operative  Gynecology.) 


'-..^'^^Miu'^tAt... 


Fig.  208.     The  Labia  Minora  Adherent  all  along 
their  free  margins.     (Kelly — Operative  Gynecology.) 


Fig.  209.  Imperforate  Hymen.  There  is  no 
vaginal  opening,  the  urethra  being  the  only  opening 
present  in  the  vestibule.  (Montgomery — Practical 
Gynecology.) 


224 


GYNECOLOGIC    DIAGNOSIS 


Laiceration  from  Labor.  Laceration  of  the  perineiiin  and  vagina  in 
labor  produces  changes  varying  all  the  way  from  a  moderate  enlargement  of 
the  vaginal  orifice  to  complete  destruction  of  the  perineum,  vith  exposure  of 
.  the  rectal  mucosa  and  incontinence  of  feces. 

Fig.  198  shows  a  widening  of  the  vaginal  opening,  due  to  a  moderate 
second  degree  tear  of  the   perineum.     The   various   methods   of  testing  the 


Fig.  210.  Hemjtocolpos,  which  may  result  from  imperforate  hymen  or  from  atresia  at  the  lower 
portion  of  the  vagina.  The  menstrual  blood  has  not  yet  distended  the  uterus.  (Montgomery — Practical 
Gynecc!o(}\.) 


Fig.  211.  Imperforate  Hymen,  with  Uterus  and 
Tubes  distended  with  menstrual  blood.  (Ashton — 
Practice  of  Gynecology.) 


.# 

r,     ^ 

^n^^ 

'y^^y 

>  S 

^^^|&|K£V7 

jf&^S^^ 

( 

I 

1          ^y 

/ 

jA 

\^ 

^ 

rb, 

■1 

1 

1  i 

i 

i 

1 

Fig.  212.  The  appearance  of  the  external  gen- 
itals in  a  case  of  Absence  of  the  Vagina.  (Kelly 
— Operative    Gynecology.) 


LACERATIONS    ABOUT   VULVA   AND   PERINEUM 


225 


Fig.  213.  The  appearance  of  the  external  gen- 
itals in  a  case  of  Double  Vagina.  (Kelly — Operative 
Gynecology.) 


Fig.  214.  Same  case  as  Fig.  213,  with  Speculum 
Introduced,  exposing  the  two  vaginal  canals  and  the 
half  cervix  at  the  top  of  each.  (Kelly — Operative 
Gynecology.) 


Fig.  215.  Complete  Laceration  of  the  Perineum.  The  sphincter  ani  muscle  has  been  torn  and  the 
ends  are  separated.  The  small  dark  area  is  an  exposed  portion  of  the  red  mucosa  of  the  rectum.  (Hirst — 
Diseases  of  Women.) 


226 


GYNECOLOGIC   DIAGNOSIS 


Fig.   21C.     Another   case    of   Laceration   through   the   Perineum   into    the    Rectum.      Notice   the    separation    of 
the  sphincter  ends  and  also  the  patch  of  rectal  mucosa.      (Hirst — Diseases  of  Women.) 


Fig.  217.  Representation  of  the  conditions  present  in  an  old  L^aceration  through  the  Sphincter  Ani. 
Notice  the  wide  separation  of  the  sphincter  ends  and  also  the  exposed  rectal  mucosa.  Each  end  of  the  torn 
sphincter  ani  muscle  is  indicated  by  a  slight  dimple  in  the  skin.      (Kelly — Operative   Gynecology.) 


LACERATIONS   ABOUT   VULVA   AND   PERINEUM 


227 


Fig.  218.  The  scar  and  opening  resulting  from 
a  "Central  Tear"  of  the  perineum.  This  is  a  very 
rare  condition.  The  child  passed  out  through  the  lac- 
eration-opening, situated  between  the  posterior  com- 
missure and  the  rectum,  instead  of  through  the  vag- 
inal opening  proper.  (Hart  and  Barbour — Manual  of 
Gynecology.) 


Fig.  219.  Laceration  of  the  Hy- 
men from  Rape,  in  a  girl  aged 
twelve.  The  child  died  in  ten  days 
of  peritonitis.  (Edgar — Practice  of 
Obstetrics.) 


Fig.  220.  Complete  Laceration 
of  the  Pelvic  Floor  in  an  infant 
of  eight  months,  from  Rape. 
(Edgar — Practice   of  Obstetrics.) 


integrity  of  the  pelvic  floor  are  shown  in  Chapter  i.  Fig.  222  shows  a  severe 
tear  of  the  pelvic  floor,  with  resulting  relaxation  and  loss  of  support. 

Figs.  215  and  216  show  complete  tears  of  the  perineum  into  the  rectum. 
The  red  mucosa  from  within  the  rectum  shows  at  the  site  of  the  rectal  tear. 
The  torn  ends  of  the  sphincter  ani  produce  a  slight  dimple  in  the  surface 
covering  them  (Fig.  217). 

Fig.  218  show-s  a  central  tear  of  the  perineum,  a  very  unusual  form  to 
result  from  childbirth. 


228 


GYNECOLOGIC   DIAGNOSIS 


Lacerations  from  Other  Causes.  Fig.  236  shows  a  laceration  of  tlie 
hymen  from  forcible  coitus  (rape)  in  a  girl  aged  twelve.  There  were  also 
deeper  injuries,  causing  peritonitis,  from  which  she  died  in  ten  days.  Fig. 
220  shows  a  tear  from  the  same  cause  involving  the  perineum  in  an  infant. 
Fig.  221  shows  a  deep  tear  of  the  perineum,  causing  a  recto-perineal  fistula, 
from  violent  coitus. 


Fig.   221.     Laceration    of   i'erineum   with   resulting   Fistula,    from    \iolent    Coitus.      (Hirst — Diseases 

of  Women.) 


^SWELLIXCI  ABOUT  EXTERNAL   GENITALS 

Colpocele,  Cystocele,  Rectocele.  These  swellings  appear  as  the  result  of 
lacerations.  Fig.  222  shows  a  severe  second  degree  tear,  involving  practically 
all  the  perineum  down  to  the  sphincter  ani  muscle,  and  also  a  posterior 
colpocele.  Figs.  223  and  224  show  such  a  laceration  with  the  anterior  and 
posterior  vaginal  walls  beginning  to  protrude,  and  there  is  also  protrusion 
of  the  bladder  and  rectum  (cystocele  and  rectocele).  In  such  a  condition,  if 
the  patient  be  directed  to  bear  down,  the  protrusion  will  become  still  more 
marked.  Fig.  225  shows  marked  protrusion  of  the  anterior  vaginal  wall  ac- 
companied by  the  base  of  the  bladder  (cystocele). 

The  fact  that  the  bladder  wall  is  prolapsed  along  with  the  vaginal  wall, 
is  indicated  by  the  fact  that  the  patient  has  more  or  less  difficulty  in  urinat- 
ing, and  in  some  cases  she  must  push  back  the  mass  before  she  can  urinate 
satisfactorily.     When  there  is  doubt  as  to  wliether  the  bladder  wall  comes 


SWELLING   ABOUT   EXTERNAL    GENITALS 


229 


do'^ra,  the  lowest  part  of  the  bladder  cavity  may  be  located  with  a  steel 
bougie  (Fig.  226). 

Fig.  227  sho-vvs  slight  rectocele  (protrusion  of  the  posterior  vaginal  Avail 
accompanied  by  the  anterior  rectal  wall).  Fig.  228  shows  a  large  rectocele. 
The  point  as  to  whether  or  not  the  rectal  wall  really  follows  the  prolapsed 
vaginal  wall,  may  be  settled  in  such  a  case  by  rectal  examination  (Figs.  229, 
230). 

Inflammation  of  Vulva  (erysipelas,  cellulitis).  There  are  the  usual  signs 
and  symptoms  of  acute  inflammation.  Owing  to  the  large  amount  of  loose 
cellular  tissue,  the  inflammatory  infiltration  may  cause  very  marked  swelling. 


W 


^C^v^ 


.-s 


Fig.   222.     An  old  Laceration  from  Labor.     Most  of  the  perineum  has  been  torn  and  there  is  protrusion  of 
the  posterior  vaginal  wall  (posterior  colpocele).      (Baldy — American   Textbook  of  Gynecology.) 


Hematoma  of  Vulva.  There  is  rapid  swelling  following  a  puncture  with 
a  hypodermic  needle  or  a  fall  or  other  injury.  There  is  marked  enlarge- 
ment, painful  on  pressure  and  presenting  in  a  short  time  discoloration  from 
l)lood  pigment.  ^  There  is  no  fever  nor  erysipelatous  redness  nor  other  evi- 
dence of  acute  inflammation.    Fig.  231  shows  a  hematoma  of  the  vulva. 

Edema  of  Vulva  (from  heart  or  liver  disease  or  from  pressure  by  a  pelvic 
tumor).  This  produces  a  boggy,  painless  swelling  Avhich  pits  on  pressure. 
There  is  no  evidence  of  acute  inflammation  or  of  hematoma.  There  may  be 
accompanying  edema  of  the  abdominal  Avail  and  loAver  extremities.  There  is 
found  some  internal  trouble  to  account  for  the  edema    (heart  disease  Avith 


230 


GYNECOLOGIC   DIAGNOSIS 


failing  circulation,  tumor  or  inflammatory  mass  obstructing  the  pelvic  circu- 
lation) . 

Stasis  Hypertrophy  of  Vulva.  There  is  a  gradual  development  of  tis- 
sue hypertrophy,  Avith  more  or  less  inflammatory  infiltration.  The  swelling 
is  not  particularly  painful  and  there  is  no  decided  pitting  on  pressure.  It 
is  accompanied  by  scar-tissue,  resulting  from  chronic  ulceration,  of  such 
extent  and  so  situated  at  the  vaginal  entrance  as  to  obstruct  the  lymph  and 
blood  circulation  (Figs.  232,  233,  234,  235,  236). 

Fig.  237  shows  the  scar-tissue  about  the  bony  arch,  distorting  the  tis- 
sues and  interfering  with  the  return  flow  of  blood  and  lymph. 


Fig.   223.      Cystocele    and    Rectocele    of    moderate 
extent.     (Thomas  and  Munde — Diseases  of  Women.) 


Fig.  224.  Cystocele  and  Rectocele  of  moderate 
extent.  Sectional  view.  (Thomas  and  Munde — 
Diseases   of   Women.) 


Another  cause  of  stasis  hypertrophy,  is  the  infiltration  and  hypertrophy 
due  to  the  lymph  vessels  being  choked  with  a  parasite,  the  filaria  sanguinis 
hominis.    This  is  seen  almost  exclusively  in  tropical  countries. 

Elephantiasis  of  Vulva.  The  term  "elephantiasis"  is  very  appropriately 
applied  to  the  cases  of  enormous  labial  hypertrophy,  such  as  shoAvn  in  Fig. 
238.  The  stasis  hypertrophy  previously  described  is  often  spoken  of  as 
"elephantiasis,"  but  it  does  not  seem  advisable  to  use  the  term  so  loosely  (see 
Chapter  iv). 

Varicose  Veins  of  Vulva.     These  not  infrequently  cause  marked  swelling, 


SWELLING   ABOUT   EXTERNAL   GENITALS 


231 


as  shown  in  Fig.  239.  Serious  enlargement  of  the  veins  is  found  most  fre- 
quently in  pregnancy  or  in  the  case  of  some  pelvic  tumor  or  inflammatory 
mass  obstructing  the  pelvic  circulation.  Alarming  hemorrhage  has  followed 
the  rupture  of  an  enlarged  vein  in  such  cases. 

Condylomata  of  Vulva.     From  Chronic  Irritation.     As  a  result  of  per- 
sistent irritation  and  discharge  al)out  the  vulva,  small  papillary  masses  grow 


Fig.  225.     Large   Cystocele.      (Montgomery — Practical   Gynecology.) 


from  the  skin  at  various  points  (Fig.  240).  They  may  come  from  any  per- 
sistent irritation,  though  chronic  gonorrhea  is  the  most  frequent  cause. 
Sometimes  they  appear  in  great  profusion  and  occasionally  they  coalesce 
and  form  large  papillary  masses  (Fig.  241).  These  papillary  growths  are 
called  pointed  condylomata,  in  contradistinction  to  the  flat  condylomata 
which  are  usually  due  to  syphilis. 

From  Syphilis.    In  secondary  syphilis,  white  areas  with  infiltration  suf- 


232 


GYNECOLOGIC    DIAGNOSIS 


>«^ 


Fig.  226.     Testing  for   Cystocele  with   Sound   introduced  into  bladder.      (Ashton — Practice   of   Gynecology.) 


Fig.   227.      Small   Rectocele.      (Hirst — Diseases   of    Women.) 


SWELLING   ABOL'T   EXTERNAL    GENITALS 


233 


ficient,  to  raise  them  above  the  surface,  often  appear  about  the  external  geni- 
tals. Ther  may  be  few  or  many  (Figs.  242,  243),  and  they  may  be  raised 
much  or  little.  They  are  usually  flat  condylomata,  only  rarely  being  pointed 
or  papillary  (Fig.  244). 

Vulvo-vaginal  Gland  Cyst  or  Abscess.  The  swelling  has  much  the  same 
appearance  whether  it  be  a  cyst  or  an  abscess.  Figs.  245  and  246  show  abscesses 
of  the  glands.    Fig.  247  shows  a  cvst  of  the  gland. 


Fig.   228.      Large  Rectoccle.      (Hirst — Diseases  of   IVoiiicn.) 


Figs.  229  and  230.  Method  of  Differentiating  between  Rectocele  and  Posterior  Colpocele.  The  index 
finger  in  the  rectum  determines  whether  or  not  the  rectal  wall  follows  the  prolapsing  vaginal  wall.  The 
hand  should  be  gloved.     Fig.  229,   Rectocele.     Fig.  230,  No  Rectocele.      (Ashton — Practice  of  Gynecology.) 


234 


GYNECOLOGIC    DIAGNOSIS 


Fig.   231.     Hematoma  of  the  Vulva.     (Hirst — Diseases  of  Women.) 


Fig.   232.     Stasis  Hypertrophy  of  the  Labia  Minora.      {Uirst^Diseases  of  Women.) 


SWELLING    ABOUT   EXTERNAL   GENITALS 


235 


Hypertrophy  of  Labia.  The  hypertrophies  affect  principally  the  labia 
ininora,  either  the  free  portion  on  one  or  both  sides  (Fig.  248)  or  that  portion 
extending  up  over  the  clitoris  as  the  prepuce.  The  hypertrophied  portions 
contain  mnch  redundant  tissue   and   are   corrugated  and  usually  somewhat 


Fig.   233.      Stasis  Hypertrophy  of  the  Vulva.      (Hirst — Diseases  of   Women.) 


Fig.   234.     Stasis  Hypertrophy  of  the  Vulva.      (Hhst— Diseases  of   Women.) 


236 


GYNECOLOGIC   DIAGNOSIS 


Fig.  23S.  Stasis  Hypertrophy  about  external 
genitals  and  edema  from  pregnancy.  (Dickinson — 
American   Textbook  of  Obstetrics.) 


Fig.  236.  So-called  Elephantiasis — probably  stasis 
hypertrophy.  (Byford,  after  Winkel — Manual  of 
Gynecology.) 


Fig.  237.  Stasis  Hypertrophy  of  Vulva,  with 
enlarged  parts  raised  so  as  to  show  the  ulceration 
and  scar-tissue  about  the  pubic  arch.  (Kiliani — 
Surgical  Diagnosis.) 


Fig.  238.     Elephantiasis  of  the  Labia.     (Baldy- 
American  Textbook  of  Gynecology.) 


SWELLING   ABOUT    EXTERNAL    GENITALS 


237 


Fig.   239.     Varicose  Veins  of  the  Vulva.      (Hirst — Diseases  of   Women.) 


Fig.  240.     Small    Masses    of    Condylomata. 
Practical   Gynecology.) 


(Gilliam- 


Fig.  241.  The  whole  vulvar  re- 
gion occupied  by  Massed  Condylo- 
mata. (Kuestner — Kurxes  Lchrbuch 
der   Gynaekologie.) 


238 


GYNECOLOGIC   DIAGNOSIS 


Fig.   242.      Syphilitic  Infiltration  and  Condylomata  about  the  vulva.      (Hirst — Diseases  of  Women.) 


Fig.   243.      Syphilitic    Condylomata.      Flat   variety.      (Bovee — Practice   of    Gynecology.) 


SWELLING   ABOUT   EXTERNAL    GENITALS 


239 


pigmented.  In  some  cases  the  hypertrophy  becomes  very  marked,  as  in  the 
Hottentot  apron,  shown  in  Fig.  249. 

Hypertrophy  of  Clitoris.  This  is  much  rarer  than  hypertrophy  of  labia. 
Occasionally  the  clitoris  is  considerably  enlarged.     Fig.  250  shows  such  a  case. 

Malignant  Disease  of  Labia  or  Clitoris.  Malignant  disease  (carcinoma  or 
sarcoma)  appears  upon  the  labia  as  a  small  reddened  nodule,  which  later 
ulcerates.    Fig.  204  shows  a  beginning  carcinoma  of  left  labium  majus.     Fig. 


Fig.   244.      Syphilitic   Condylomata.      Pointed  variety.      (lihst^Diseascs  of   Women.) 


251  shows  a  small  carcinoma  of  labium  minus.  Figs.  252  and  253  show  car- 
cinoma of  the  labium  at  a  later  stage.  Fig.  254  shows  an  advanced  carcinoma 
of  the  vulvo-vaginal  gland.  Fig.  255  shows  a  sarcoma  of  the  labium.  Fig. 
205  shows  a  carcinoma  of  clitoris. 

Non-malignant  Tumor  of  Labia  or  Clitoris.  Fibromata  and  lipomata  and 
cysts  occur  here,  though  not  very  frequently.  Fig.  256  shows  a  small  fibroma 
of  the  left  labium  majus.  Fig.  257  shows  a  larger  solid  tumor  of  the  labium. 
Fig.  258  shows  a  number  of  small  cysts  on  the  labium.  Figs.  259  and  260 
show  large  labial  cysts.    Fig.  261  shows  a  cyst  of  the  clitoris. 

Pudendal  Hernia.     A  hernia  of  intestine  or  omentum  or  other  intraperi- 


240 


GYNECOLOGIC   DIAGNOSIS 


toneal  structure,  may  take  place  througli  the  inguinal  canal  and  appear  in  the 
labium  majus  of  that  side  (Fig.  262). 

Another  form  of  pudendal  hernia  is  that  which  comes  by  way  of  the 
vagina  (Fig.  263),  the  protrusion  taking  place  in  front  of  the  uterus  in  some 
cases  (Fig.  308)  and  behind  the  uterus  in  others. 

Pudendal  Hydrocele.  A  collection  of  fluid  occasionally  occurs  in  the 
canal  of  Xuck,  forming  a  hydrocele,  which  corresponds  to  hydrocele  of  the 
cord  in  the  male. 


■-^r«- 


Fig.   245.     Abscess  of  \'ulvo-vaginal   Gland,   left  side.      (Kelly — Operative   Gynecology.) 


Tumor  of  Round  Ligament.  Fibromyoma  of  the  round  ligament  is  a  rare 
condition  and  one  that  causes  much  distortion  of  the  structures  about  the 
inguinal  canal,  consequently  it  is  likely  to  lead  to  an  erroneous  diagnosis.  It 
should  be  considered  whenever  there  is  a  peculiar  swelling  in  the  neighbor- 
hood of  the  inguinal  canal. 

Prolapse  of  the  Urethral  Mucosa  (Fig.  264).  This  occurs  to  a  slight  ex- 
tent in  many  women  who  have  borne  children  or  have  had  inflammation  of 
the  urethra.    Not  infrecpiently  the  protrusion  is  marked  and  no  doubt  leads  in 


SWELLING   ABOUT   EXTERNAL    GENITALS 


241 


Fig.   246.     Another  case  of  Abscess  of  ^'ulvo-v:lL;l;..^l   Gland,   right  side.      (Hirst — Diseases  of  Women.) 


Fig.  247.     Cyst   of  the   Vulvo-vaginal   Gland.      (Montgomery — Practical   Gynecology.) 


242 


GYNECOLOGIC    DIAGNOSIS 


many  cases  to  an  erroneous  diagnosis  of  caruncle.  The  prolapsed  mucosa  en- 
circles a  considerable  part  of  the  circumference  of  the  meatus,  and  a  close 
inspection  will  show  that  the  small  mass  presents  the  smooth,  though  irregu- 
lar, surface  of  hypertroj)hied  mucosa,  instead  of  the  papillary  projections 
usually  present  in  urethral  caruncle.     Again,  the  meatus  is  much  widened 


Fig.   248.     Hypertrophy   of  the  Labia   Minora.      (Hir.st — Diseases  of   Women.) 


Fig.  249.  Enormous  Hypertrophy  of  the  Labia  Minora — the  so-called  "Hottentot  Apron."  The  first 
cut  shows  the  patient  standing,  with  the  hypertrophied  labia  hanging  between  the  thighs.  The  second  cut 
shows  the  patient  on  her  back,  with  the  labia  separated.      (Garrigues,  after  Zweifel — Diseases  of  Women.) 


SWELLING    ABOUT   EXTERNAL   GENITALS 


243 


from  the  previous  injuiy  or  inflammation,  and  the  prolapsing  of  the  mucosa 
may  bring  into  view  the  orifice  of  the  duct,  or  Skene's  gland,  on  one  or  both 
sides  (Fig.  44). 

Urethral  Caruncle   (Fig.  265).     This  is  a  distinct    new    growth,    usually 
papillary  in  form,  springing  from  the  region  of  the  meatus.     It  may  have  a 


Fig.    250.      Hypertrophy   uf   the   Llituns.      illirbt — Diseases  of   U'odicii.) 


Fig.   251.      Carcinoma  of  Labium  Minus,  beginning.      (Hirst — Diseases  of  Women.) 


244 


GYNP^COLOGIC   DIAGNOSIS 


Fig.  252.      Carcinoma   of-  Labium   at   a   later   stage.      (Hirst — Diseases   of   Women.) 


Fig.  253.     Carcinoma  of  I,abium  in  a  still  later  stage.      (Hirst — Diseases  of   Women.) 


SWELLING   ABOUT   EXTERNAL   GENITALS 


245 


narrow  pedicle  or  a  broad  attachment,  but  does  not  tend  to  encircle  the  meatus 
as  does  prolapsed  mucosa. 

Malignant  Disease  of  Urethra.  This  starts  usually  in  some  small  spot  of 
irritation  about  the  meatus,  and  in  the  early  stage  presents  a  small  ulcer  or 
induration.  Later  the  infiltration  involves  the  vestibule,  urethra  and  adjacent 
tissues. 

Suburethral  Abscess.    This  consists  of  a  pouch  formed  by  a  diverticulum 


«<«**^'^ 


Fig.   254.     A  large  Carcinoma  of  the  left   Vulvo-vaginal   Gland.      (Kelly — Operative   Gynecology.) 

from  the  urethra,  usually  from  the  inferior  wall.  Inflammation  and  suppura- 
tion take  place  in  this  pouch,  which  may  or  may  not  drain  irregularly  into  the 
urethra.  When  distended,  it  may  project  at  the  vaginal  orifice  (Fig.  266) 
like  a  small  cyst  of  the  anterior  vaginal  wall.  Fig.  267  gives  a  clear  idea  of 
the  condition. 

Prolapse  of  Uterus   (Fig.  268).     When  the  uterus  prolapses  sufficiently, 


246 


GYNECOLOGIC    DIAGNOSIS 


Fig.   255.      Sarcoma    of   Labium.      (Hirst — Diseases   of    Women.) 


Fig.   256.     A   small   Fibroma   of   left   Labium   Majus. 
(Baldy — American   Textbook   of   Gynecology.) 


Fig.  257.    A  large  Fibroma  of  the  Labium. 
(Montgomery- — Practical  Gynecology.) 


SWELLING   ABOUT   EXTERNAL    GENITALS 


247 


Fig.   258.      Small    Cysts    of   the    Left   Labium   Minus.      (KeUy— Operative   Gynecology.) 


i 


Fig.  259.     A  large  Labial   Cyst,      {mrst— Diseases  of   Women.) 


248 


GYNECOLOGIC   DIAGNOSIS 


Fig.   260.     Another  large  Labial  Cyst.      (Hirst — Diseases  of   Women.) 


Fig.  261.     A  Cyst  of  the  Clitoris.     (Kellj- — Operative  Gynecology.) 


SWELLING   ABOUT   EXTERNAL   GENITALS 


249 


Fig.   262.     An  Inguinal  Hernia  becoming  Pudendal.      (Dudley — Practice  of  Gynecology.) 


Fig.   263.     A  Pudendal  Hernia  which  came  by  way  of  the  Vagina.      (H.  Macnaughton-Jones,  after  Winckel— 

Diseases  of  Women.') 


250 


GYNECOLOGIC   DIAGNOSIS 


the  firm  cervix,  with  the  external  os  near  the  center,  appears  at  the  vestibule 
(Fig.  269),  or  it  may  come  farther  out  as  shown  in  Fig.  270,  or  it  may  come 
still  farther,  so  that  the  entire  uterus  is  outside  the  body  (Fig.  271). 

The  bladder  may  or  may  not  prolapse  along  with  the  uterus.  Fig.  272 
represents  a  case  in  which  the  bladder  does  not  prolapse.  Fig.  273  represents 
a  case  in  which  the  bladder  does  come  down  Avith  the  displaced  uterus. 
The  method  of  locating  the  bladder  by  the  introduction  of  a  sound,  is  shown 


.  XFirT" 


Fig.   264.     Prolapse  of  the  Urethral  Mucosa, 
gomery — Practical    Gynecology.) 


(Mont- 


Fig.   265.     Urethral    Caruncle.       (Montgomery- 
Practical    Gynecology.') 


in  Fig.  274.  Ulcers  of  various  sizes  and  shapes,  may  appear  on  the  exposed 
irritated  surfaces.  Such  ulceration  is  shown  in  Fig.  271.  Prolapse  may  occur 
in  a  woman  who  has  never  had  a  child  (Fig.  275)  or  even  in  the  virgin  (Fig. 
276).  The  position  of  the  fundus  is  made  out  by  recto-abdominal  palpation, 
as  indicated  in  Fig.  277. 

Elongation  of  the  Cervix  produces  a  condition  which  is  not  infrequently 
mistaken  for  prolapse.  If  the  hypertrophy  atfects  only  the  infravaginal  por- 
tion of  the  cervix  (Fig.  278,  a)  the  vaginal  walls  are  not  carried  down  but 


SWELLING   ABOUT    EXTERNAL    GENITALS 


251 


Fig.   266.     Suburethral   Abscess.      View  from  in  front.      (Kelly — Operative   Gynecology.') 


252 


GYNECOLOGIC   DIAGNOSIS 


Fig.  267.     Testing  for  Suburethral  Abscess.     (Ashton  Fig.    268.      Prolapse    of    the    Uterus,    showing    the 

— Practice    of    Gynecology.)  various     steps     in     the     process.        (Kelly — Operative 

Gynecology.) 


Fig.  269.     A  case  of  Prolapse  of  the  Uterus.     The  cervix  is  at  the  vestibule.      (.U'lrst— Diseases  of  Women.) 


PROLAPSE    OF   UTERUS 


253 


remain  in  normal  position,  producing  the  condition  shown  in  Figs.  279  and 
280.  When  the  elongation  affects  the  supravaginal  portion  (Fig.  278,  c),  both 
vaginal  walls  are  carried  down  with  the  protruding  cervix,  producing  a  condi- 
tion (Fig.  281)  very  likely  to  be  mistaken  for  uterine  prolapse,  unless  the 
depth  of  the  uterine  cavity  be  measured  or  the  body  of  the  uterus  be  carefully 
outlined  by  bimanual  palpation.  In  these  cases  the  dragging  of  the  relaxed 
and  redundant  vaginal  walls,  seems  to  be  an  important  factor  in  producing 


Fig.   270.     Another  case   of  Prolapse   of  the  Uterus.     The  uterus  comes  still   farther  out. 


254 


GYNECOLOGIC    DIAGNOSIS 


Fig.   271.     Another    case    of    Prolapse    of   the    Uterus.      The    uterus   and   vagina    lie    outside    the    body.      The 
ulceration,  so  frequent  in  these  cases,   is  very  evident.      (Hirst — Diseases  of   Women.) 


Fig.   272.     Prolapse    of    the    Uterus.      Sectional    view.      The    bladder    remains    in    place.       (Kelly — Operative 

Gynecology.) 


DIAGNOSIS   OF   PROLAPSE 


255 


Fig.  2'/ 5.     Prolapse   of   the  Utcrvis   and  Bladder.      (Doederleiu   and   Krcenig — ()perati:-e   Gynackologie.) 


Fig.   274.     Testing    for    Prolapse    of    the    Bladder    with    the    uterus,    by    means    of    a    sound    in    the    bladder. 

(Ashton — Practice   of   Gynecology.') 


256 


GYNECOLOGIC    DIAGNOSIS 


Fig.   275.     Prolapse  of  the  Uterus  in-  a  Nullipara.      (Hirst — Diseases  of  Women.) 


Fig.   276.     Prolapse  of  the  Uterus  in  a  Virgin.     (Kuestner — Kiir::es  Lehrbudi   der  Gynaekologic.\ 


DIAGNOSIS    OF    PROLAPSE 


257 


the  elong-ation  of  the  cervix.  When  the  hypertrophy  or  stretching,  as  the 
ease  may  be,  affects  the  intermediate  portion  of  the  cervix  (Figs.  278,  b),  the 
anterior  vaginal  wall  is  usually  carried  do^m  while  the  posterior  wall  remains 
in  place  (Fig.  282).  The  time-honored  division  of  the  cervix  into  three  por- 
tions, as  indicated  in  Fig.  278,  is  convenient  for  fixing  in  mind  the  conditions 
ordinarily  present  in  these  cases,  but  it  must  be  remembered  that  in  manv 


Fig.   277.     Locating  the   body   of  the   L'terus   by   recto-abdominal   palpation    in   a   case   of  suspected   Prolapse. 

(Ashton — Practice  of  Gynecology.) 


Fig.   278.     The    Three    Divisions    of    the    CervLx:  Fig.  279.     Hypertrophy   of  the   Infravaginal   Por- 

(a)  Infravaginal  Portion,     (b)  Intermediate  Portion,  tion    ot  the    Cervix.      (B/ford — Manual   of   Gynecol- 

(c)      Supravaginal     Portion.        (Byford — Manual    of  ogy.) 
Gynecology.) 


OYiSTECOLOGIC   DIAGNOSIS 


Fig.   280.     Hypertrophy  of  the  Infravaginal  Portion  of 
the    Cervix.      (Kelly — -Operative    Gynecology.) 


Fig.  281.  Hypertrophy  of  the  Supra- 
vaginal Portion  of  the  Cervix,  carry- 
ing down  the  vagina  and  cervix  to  the 
vulva.  The  uterine  cavity  in  this 
case  measures  five  and  a  half  inches. 
An  area  of  erosion  is  present  on  the 
posterior  lip  of  the  cervix.  (Gil- 
liam— Practical    Gynecology.) 


Fig.  282.  Hypertrophy  of  the  Intermediate  Por- 
tion of  the  Cervix,  carrying  down  the  anterior  vag- 
inal wall  and  bladder  but  not  the  posterior  vaginal 
wall.      (r>yford — Manual  of  Gynecology.) 


Fig.   283.       A     specimen  presenting     a     peculiar 

Hypertrophy   of   the    Cervix.  The    posterior   vaginal 

wall  is  carried  down  but  not  the  anterior.      (Herman 
— Diseases  of  Women.) 


TUMOR    OF    UTERUS 


259 


cases  the  vaginal  wall  does  not  run  very  much  further  up  on  the  posterior 
part  of  the  cervix  than  it  does  on  the  anterior  and,  consequently,  elongation 
of  the  middle  or  intermediate  portion  of  the  cervix  does  not  always  carry 
down  the  anterior  vaginal  wall  and  leave  the  posterior  in  place — in  fact,  in 
the  case  shown  in  Fig.  283,  it  has  carried  down  the  posterior  wall  and  left 
the  anterior. 

The  differentiation  from  prolapse  of  the  uterus  is  made  by  locating  the 
fundus  uteri  at  about  the  normal  position  in  the  pelvis,  by  vagino-abdominal 
or  recto-abdominal  palpation,  and,  if  necessary,  by  sounding  the  uterus  to 
determine  the  length  of  the  uterine  cavity.     In  elongation,  the  cavity  is  in- 


Fig.   284.      Pediculated   Fibroid    Tumor    of   the    Uterus,    protruding   at   the   vulva.      (Kelly — 

Operative   Gynecology.) 


creased  in  length  sufficiently  to  account  for  the  appearance  of  the  cervix  at 
the  vulva.  In  prolapse  of  the  uterus,  there  is  usually  some  elongation  of  the 
supravaginal  portion  of  the  cervix  by  the  dragging  of  the  prolapsing  vaginal 
walls,  but  it  is  of  secondary  importance.  In  the  cases  in  which  the  elongation 
of  the  cervix  is  the  principal  lesion,  there  is  usually  some  prolapse  of  the 
uterus,  due  to  the  dragging  of  the  heavy  cervix. 

Tumor  of  Uterus.     A  mass  appearing  at  the  vulva,  may  be  a  pediculated 
fibroid   (Fig.  284)   or  a  malignant  tumor  from  the  uterus. 


260 


GYNECOLOGIC   DIAGNOSIS 


Fig.    285.      Complete    Inversion    of   the   Uterus,    forming  a   large    mass   at    the   vulva.      This    is   a   post- 
partum inversion  and  the  placenta  is  still  attached  to   the  turned-out  fundus  uteri.      (Williams — Obstetrics.) 


Fig.  286.     A  small  Cyst  of  the  Vaginal  Wall.      (Hirst — Diseases  of   Women.) 


VAGINAL   EXAMINATION 


261 


Inversion  of  Uterus  (Fig.  285).  This  rare  condition  may  produce  an  ap- 
pearance very  closely  resembling  a  necrotic,  bleeding  tumor  protruding  from 
the  vulva.     The  internal  conditions  are  shown  in  Fig.  293. 

Vaginal  Cyst.  This  may  be  confounded  with  cystocele  or  vaginal  hernia 
or  suburethral  abscess.  The  differential  diagnostic  points  are  the  absence  of 
inflammation,  the  distinct  fluctuation,  the  tenseness  of  the  sac  containing  the 
fluid  and  its  attachment  to  some  part  of  the  vagina.  Figs.  286  and  287  shoAv 
such  A^aginal  cj^sts. 


Fig.  287.     A  medium-sized  Vaginal   Cyst,   caught  with  a  forceps   and   brought  into  view.      (Hirst — Diseases 

of  Women.) 


POINTS  IN  THE  VAGINAL  EXAMINATION 


ROUGHENING  OF  VAGINAL  WALLS 

Astringent  Douche.  Any  astringent  douche,  for  example,  one  containing 
alum  or  bichlorid,  will  cause  temporary  roughening  of  the  vaginal  Avail.  But 
there  is  no  particular  tenderness.  ^ 

Inflammation.     It  is  found  in  acute  vaginitis,  simple  or  gonorrheal,  and 


262  GYNECOLOGIC   DIAGNOSIS 

in  some  cases  of  chronic  vaginitis.  In  addition  to  the  rough  granular  feel, 
there  is  tenderness  of  the  wall,  and  the  speculum  examination  shows  red- 
dening. 

TENDERNESS  ON  VAGINAL  PALPATION 

Inflammation  of  Vaginal  Entrance.  The  tenderness  is  noticed  as  soon  as 
the  examining  finger  begins  to  enter  the  vagina.  There  may  be  diffuse  red- 
ness of  the  surface  around  the  vaginal  orifice  or  there  may  be  simply  reddened 
areas  that  are  tender  on  pressure  or  there  may  be  abrasions  or  slight  fis- 
sures or  there  may  be  one  or  more  distinct  ulcers. 

Inflammation  of  Vulvo-vaginal  Gland  or  Duct.  There  is  swelling  and 
tenderness  at  the  site  of  the  gland  and  redness  about  the  duct,  and  in  some 
cases  pus  may  be  squeezed  from  the  duct. 

Hyperesthesia  of  Vaginal  Entrance.  There  is  great  exaggeration  of  the 
reflex  sensibility  of  the  tissues  immediately  about  the  vaginal  orifice,  and  yet 
no  evidence  of  inflammation  or  flssure  or  ulcer  or  other  adequate  cause  for 
pain.  In  some  cases  the  reflex  excitability  is  so  great  that  contact  causes 
spasm  of  the  levator  ani  and  associated  muscles  to  such  an  extent  as  to  pre- 
vent the  examination.  This  uncontrollable  spasmodic  closure  of  the  vaginal 
orifice  is  known  as  '' vaginismus." 

Inflammation  of  Vagina.  There  is  purulent  discharge  and  the  vaginal 
walls  are  rough  and  hot.  Speculum  examination  shows  marked  reddening  of 
the  walls  (arterial  congestion)  and  also  discharge  upon  them. 

Inflammation  of  Urethra.  The  tenderness  is  along  the  lower  part  of  the 
anterior  vaginal  wall  and  is  complained  of  when  pressure  is  made  along  the 
course  of  the  urethra.  There  may  be  distinct  thickening  about  the  urethra, 
which  may  be  felt  as  a  firm  cord  beneath  the  pubic  arch.  In  most  cases  there 
is  redness  about  the  meatus,  and  some  discharge  may  be  pressed  out  by  com- 
pressing the  urethra  from  above  downward  (Figs.  42,  43). 

Inflammation  or  Other  Painful  Aff'ection  of  the  Bladder.  Pain  is  caused 
by  pressure  upAvard  along  the  middle  of  the  anterior  vaginal  wall,  which  lies 
against  the  base  of  the  bladder.  There  are  also  the  symptoms  of  bladder  ir- 
ritation (frequent  urination,  painful  urination),  and  also  the  findings  on  uri- 
nary analysis. 

Inflammation  or  Other  Painful  Affection  of  the  Rectum.  Pain  is  caused 
by  pressure  backward  along  the  posterior  vaginal  wall  (Fig.  60).  There  is 
also  evidence  of  rectal  irritability  (pain  on  defecation,  rectal  tenesmus),  and 
possibly  the  passage  of  blood  or  mucus. 

Inflammation  Around  Uterus  (cellulitis,  salpingitis,  pelvic  peritonitis). 
Pain  is  caused  by  pressure  on  the  vaginal  wall  around  the  uterus,  either  in 
front  of  the  cervix  or  behind  it  or  at  one  side.  Pain  is  caused  also  by  any  at- 
tempt to  move  the  uterus,  as  by  pushing  on  the  cervix. 


VAGINAL   EXAMINATION 


263 


MASS  FELT  IN  VAGINAL  PALPATION 

Prolapsed  Vaginal  Wall  (colpocele).  The  vaginal  wall  is  more  redundant 
than  it  ought  to  be  and  part  of  it  descends  toward  the  opening.  It  may  be 
the  anterior  vaginal  wall   (anterior  colpocele)   or  the  posterior  vaginal  wall 


Fig.   288.     A    small    Pediculated    Fibroid    of    Uterus,    projecting    into    the    vagina. 

Gynecology.) 


(Montgomery — Practical 


Fig.   289.     A    large    Pediculated    Uterine    Fibroid  Fig.   290.     A  Pediculated  Fibroid,  with  the  sound 

lying  in  the  vagina.      (Thomas  and  Munde — Diseases        in    place    to    differentiate    it    from    inversion    of    the 
9/  Women.)  uterus.      (Dudley — Practice   of    Gynecology.) 


264 


CtYxecologic  diagnosis 


big.  291.     A  Sarcoma  of  the  Uterus  projecting  into  the  vagina  and  causing  partial  inversion  of  the   uterus 

(Kelly — Ope  ratk-e  Gyii  ecology. ) 


X 


Fig.  292.      Grape-like     Sarcoma    springing    from  the  Cervix  uteri  and  forming  a  mass  in  the  vagina. 
(Kuestner — Kurzes   Lehrbuch   der   Gynaekologie.) 


MASS   FELT   IN   VAGINAL   PALPATION 


265 


(posterior  colpocele)    (Fig.  222)   or  both.     Tlie  mass  presents  the  character- 
istics of  relaxed  vaginal  wall.    There  is  no  distinct  firm  body  in  it. 

Prolapse  of  Bladder  (cystocele).  In  some  cases  of  prolapse  of  the 
anterior  vaginal  wall,  the  bladder  follows  the  vaginal  Avail  (Fig.  224).  This 
is  known  as  cystocele,  as  previously  explained.  The  bladder  wall  is  soft  and, 
therefore,  can  not  be  felt  distinctly  in  the  mass,  as  the  uterus  can.  It  is  noticed, 
however,   that  there   is  much  moie   soft  tissue   in  the   mass  than  would  be 


Fig.  293.     Inversion  of  the  Uterus,   forming  a  mass  in  the  vagina.      (Kelly — Operative  Gynecology.) 


furnished  by  the  prolapsed  vaginal  wall  and,  as  the  bladder  lies  next  to  the 
vagina,  it  is  to  be  assumed  that  this  extra  tissue  is  bladder  wall.  ►Sometimes 
there  is  enough  urine  in  the  prolapsed  pouch  of  bladder  to  give  fluctuation. 
Usually  there  is  some  bladder  irritability  (frequent,  painful  urination),  and  in 
some  cases  the  patient  has  found  that  she  must  push  back  the  mass  each  time 
before  she  can  urinate  satisfactorily.  If  there  is  still  doubt  as  to  Avhether  or 
not  the  bladder  descends  with  the  vaginal  wall,  and  it  is  important  to  know 


266 


GYXECOLOGIC    DIAGNOSIS 


Fig.  294.     Beginning  Inver- 
sion  of  the   Uterus. 


Fig.    295.      Submucous    Fi- 
broid with  short  pedicle. 


Fig.  296.  Submucous  Fi- 
broid and  beginning  Inver- 
sion. 


Fig.  297.     Partial  Inversion 
of  Uterus. 


Fig.    29S.       Submucous    Fi- 
broid witb  long  pedicle. 


Fig.  299.    Pediculated  Fi- 
broid and  partial  Inversion. 


Fig.    300.      Complete   Inver- 
sion   of   Uterus. 


Fig.  301.  Pediculated  Fi- 
broid filling  upper  part  of 
vagina. 


Fig.  302.  Complete  In- 
version of  Uterus,  with  a 
pediculated  subperitoneal 
Fibroid  occupying  the  nor- 
mal   site    of    the   uterus. 

Figs.    294    to    302.       Inversion    of    the    Uterus    and     Conditions    that    Simulate    it.       (Dudley — Practice    of 

Gynecology.) 


J 


MASS   FELT    IN    VAGINAL   PALPATION 


267 


certainly,  introduce  a  steel  urethral  bougie  (about  No.  20F)  and  see  if  the  tip 
passes  easily  into  the  mass  (Fig.  226). 

Prolapse  of  Anterior  Wall  of  Rectum  (rectocele).  The  anterior  wall  of 
the  rectum  may  follow  the  posterior  vaginal  Avail  in  its  descent'  through  the 
vaginal  orifice  (Figs.  227,  228).  A  digital  examination  per  rectum  will  quickly 
show  whether  or  not  the  cavity  of  the  rectum  extends  into  the  mass  (Figs. 
229,  230). 

Prolapse  of  Uterus  (Fig.  268).  The  cervix  is  felt  much  loAver  (closer  to 
the  vaginal  entrance)  than  normal,  or  it  may  present  at  the  vaginal  orifice  or 
even  project  far  outside  (Fig.  270).  Bimanual  examination  shoAvs  that  the 
body  of  the  uterus  also  is  lower  than  usual  (Fig.  296),  and  consequently  that 
the  condition  is  prolapse  of  the  uterus  and  not  simply  elongation  of  the  cervix. 


Fig.   303. 
Diagnosis  of  Inversion  of  the  Uterus. 


Fig.  304. 


Fig.  303  shows  the  method  of  determining  the  absence  of  the  body  of  the  uterus  from  the  pelvic 
cavity.  Fig.  304  shovi's  the  determination  of  the  presence  of  a  cup-shaped  depression  above  the  cervix. 
(Ashton — Practice  of  Gynecology.) 


Elongation  of  Cervix.  The  cervix  is  felt  much  loAver  than  it  ought  to  be. 
Bimanual  examination  shoAvs  that  the  body  of  the  uterus  is  in  normal  position. 
If  the  bimanual  examination  does  not  make  plain  the  length  and  position  of 
the  body  of  the  uterus,  the  uterus  may  be  sounded.  This  Avill  shoAv  that  the 
length  of  the  uterus  is  sufficient  to  account  for  the  Ioav  position  of  the  cervix. 
In  some  cases  the  tAvo  conditions,  prolapse  of  the  uterus  and  elongation  of 
the  cervix,  are  both  present. 

Tumor  of  Uterus.  There  is  a  solid  or  semisolid  mass  lying  in  the  vagina 
(Figs.  228,  229,  290,  291,  292).     The  finger  may  be  passed  all  around.  betAveen 


268 


GYNECOLOGIC   DIAGNOSIS 


the  mass  and  the  vaginal  wall.  When  the  finger  is  passed  around  the  mass, 
its  connection  with  the  cervix  is  felt.  It  may  spring  from  a  portion  of  the 
cervix  within  reach,  or  it  may  be  connected  with  a  pedicle  extending  up 
into  the  canal. 

Inversion  of  Uterus   (Fig.  293).     There  is  a  mass  the  size  of  the  uterus 


Fig.  305.  Differential  Diagnosis  of  Inversion 
by  means  of  the  sound.  On  all  sides  the  sound  is 
stopped  a  short  distance  within  the  cervix.  (Ashton 
— Practice  of  Gynecology.) 


Fig.   307.     A    group    of   small    Cysts   of   the   Vaginal 
Wall.      (Montgomery — Practical   Gynecology.) 


Fig.  306.  A  Pediculated  Fibroid  Causing  In- 
version of  the  Uterus.  This  shows  also  a  danger  to 
be  avoided  in  treatment.  Amputation  of  the  fibroid 
by  cutting  across  the  pedicle  at  the  level  of  the  line 
A,  B,  would  open  the  peritoneal  cavity.  (Thomas 
and  Munde — Diseases  of   Women.) 


Fig.    308. 


Anterior    Vaginal     Hernia. 
Practice    of   Gynecology.) 


(Ashton — 


MASS   FELT   IN    VAGINAL   PALPATION  269 

lying"  in  the  vagina,  having  a  raw  looking  mucous  surface  exposed.  Palpation 
of  the  upper  part  of  the  mass  shows  that  it  is  connected  with  the  cervix  by  a 
broad  pedicle,  and  the  dilated  cervical  ring  may  be  felt  around  it.  Figs.  294 
to  302  give  a  clear  idea  of  inversion  and  conditions  that  may  be  confounded 
with  it. 

Bimanual  examination  (under  anesthesia,  if  necessary)  shows  the  body 
of  the  uterus  absent  from  where  it  should  be  (Fig.  303),  and  instead  there  is 
a  cup  like  depression  above  the  cervical  ring  (Fig.  304).  Also,  a  sound  will 
not  pass  up  into  the  uterine  cavity  but  is  stopped  on  all  sides  a  short  distance 
within  the  cervical  opening  (Fig.  305).  There  may  be  inversion  associated 
with  a  tumor  (Fig.  306). 

Tumor  of  Vaginal  Wall.  This  is  usually  a  cyst.  A  rounded  mass  contain- 
ing fluid  is  felt  and,  tracing  it  up,  it  is  found  to  be  attached  to  the  vaginal 
wall  (Fig.  307).  It  can  not  be  reduced  into  the  peritoneal  cavity  like  a 
hernia,  neither  is  there  any  evidence  of  any  obstructive  bowel  disturbance. 
Solid  tumors  of  the  vaginal  wall  sometimes  occur. 

Vaginal  Hernia  (Fig.  308).  This  is  felt  as  a  soft  elastic  mass,  causing 
projection  of  the  vaginal  wall.  It  can  be  reduced  into  the  peritoneal  cavity 
but  returns  when  the  patient  coughs  or  bears  down.  It  disappears  when  the 
patient  is  in  the  knee-chest  posture,  unless  strangulated  or  incarcerated.  There 
may  or  may  not  be  symptoms  of  intestinal  obstruction,  partial  or  complete. 

Absicess  Pushing  Vaginal  Wall  Inward.  Such  an  abscess  may  arise  in  the 
connective  tissue  beside  the  cervix  or  in  the  posterior  cul-de-sac  or  in  front 
of  the  cervix  or  as  an  ischio-rectal  abscess.  It  may  arise  also  in  the  recto- 
vaginal septum. 

Rectum  Distended  With  Fecal  Masses.  If  the  fecal  masses  are  in  the 
lower  part  of  the  rectum  their  character  is  apparent,  but  if  in  the  upper  part 
of  the  rectum,  back  of  the  uterus,  they  may  be  confused  with  other  masses. 
The  characteristics  of  such  a  fecal  mass  are  that  it  is  situated  in  the  course  of 
the  rectum,  that  it  is  not  particularly  tender,  that  it  has  a  putty-like  con- 
sistency and  may  be  indented  by  the  examining  finger  and  the  dent  remains, 
that  it  may  be  moved  along  to  a  different  part  of  the  rectum  and  that  an 
enema  removes  it. 

Tumor  of  Rectum.  There  is  a  mass  felt  through  the  posterior  vaginal 
wall.  There  are  the  evidences  of  rectal  irritation  and  also  the  facts  that  may 
be  made  out  on  rectal  examination. 

Tumor  of  Bladder.  A  mass  is  felt  through  the  anterior  vaginal  Avail. 
There  are  the  evidences  of  bladder  irritation  (frequent,  painful  urination)  and 
also  the  urinary  findings. 

Mass  in  Cul-de-Sac  of  Douglas.  This  is  felt  back  of  the  cervix  and  may 
be  a  retroflexed  uterus  (Fig.  369),  a  tumor  (Fig.  368),  a  prolapsed  ovary  or 
tube  (Fig.  367),  an  inflammatory  exudate  (Fig.  377),  an  abscess  or  a  hema- 
tocele. 


270 


GYNECOLOGIC    DIAGNOSIS 


CHANGES  IN  CERVIX  UTERI  FELT  ON  VAGINAL  EXAMINATION 

Displacement  of  Cervix.  Forward  Displacement  (pointing  forward)  may 
be  due  to  backward  displacement  of  the  nterus  (Figs.  309,  310),  to  anteflexion 
of  the  cervix  (Fig.  311)  or  to  an  inflammatory  mass  or  a  tumor  back  of  the 
cervix  pushing  it  forward.  Backward  Displacement  may  be  due  to  a  distended 
bladder  (Fig.  324),  or  a  tumor  of  the  bladder,  to  an  inflammatory  mass  or  a 
tumor  in  the  front  part  of  the  cervix  pushing  it  backward  or  to  old  adhesions 
back  of  the  cervix  pulling  it  backward.  Lateral  Displacement  of  the  cervix 
may  be  due  to  an  inflammatory  mass,  a  blood  mass  or  a  tumor  at  the  side  of 
the  cervix  pushing  it  toward  the  opposite  side,  or  to  old  adhesions  or  to  scar 
tissue  in  the  vaginal  wall  on  one  side  pulling  the  cervix  to  the  same  side. 

Enlargement  and  Distortion  of  the  Cervix  may  be  caused  by  inflamma- 
tion with  eversion  of  mucosa   (Fig.  312),  or  by  laceration  with  eversion  of 


Fig.   309.  Fig.   310. 

The  Relation  of  the  Cervix  to  the  Examining  Finger. 

Fig.  309.  Retroversion  of  the  Uterus,  showing  the  Relation  of  the  Cervix  to  the  examining  finger. 
Compare  this  with  Fig.  310,  which  shows  the  relation  of  the  cervix  to  the  examining  finger  when  the  uterus 
is  in  normal  position.      (Keating  and   Coe — Clinical   Gynecology.) 


mucosa  (Figs.  313  and  314),  or  by  chronic  inflammatory  infiltration  and  ob- 
struction of  gland  ducts  from  scar-tissue,  causing  cystic  degeneration  (Fig. 
318),  or  by  a  fibroid  tumor  of  the  cervix  or  by  a  malignant  tumor  of  the  cervix. 
Idiopathic  elongation  of  the  cervix,  also,  may  cause  it,  but  that  is  a  very  rare 
condition. 

Softening"  of  the  Cervix  may  be  due  to  normal  pregnancy  or  to  extra- 
uterine ]3regnancy  or  to  a  recent  pregnancy  (terminated  by  labor  or  miscar- 
riage). In  Fig.  319,  the  softened  portion  is  represented  by  the  dotted  area. 
This  feels  soft,  like  the  vaginal  wall  or  like  velvet,  as  explained  in  Chapter 
I.  It  has  been  aptly  said  that  "the  cervix  normallj^  has  about  the  consistencj^ 
of  the  tip  of  the  nose.     When  it  is  soft  as  the  lip,  look  out  for  pregnancy." 


CHANGES    IN    CERVIX   UTERI 


271 


Tliis  softening  begins  at  the  lower  part  of  the  cervix  in  the  first  few  weeks  of 
pregnancy  and  graclually  progresses  upward  nntil,  in  the  last  month,  the 
whole  cervix  is  so  softened  that  it  is  sometimes  hardly  felt  in  the  examina- 
tion. That  this  is  a  softening,  and  not  a  shortening  as  was  formerly  sup- 
posed, is  shown  in  Fig.  320,  where  it  is  seen  that  the  cervix  at  term  is  still  of 
normal  length.  Occasionally  marked  chronic  congestion,  from  the  presence 
of  a  tumor  or  inflammatory  mass,  will  he  accompanied  by  some  softening  of 
the  cervix. 


Fig.   311.     Anteflexion    of   the    Cervix   Uteri.      In    this    condition    the    axis    of   the    cervix   points    toward   the 
examiner,   as  in  retroversion,  though  the   corpus   uteri   is   well   forward. 

Hard  Nodule  in  the  Cervix  may  be  due  to  scar-tissue  from  laceration, 
to  a  fibroma,  to  beginning  malignant  disease  (Fig.  321)  or  to  a  glandular  cyst 
(Fig.  322).  In  scar-tissue,  the  induration  corresponds  Avith  the  scar  and  fol- 
lows the  course  of  the  scar,  and  it  does  not  increase  in  size  under  observation. 
In  cystic  disease  (Chapter  vi)  if  the  nodule  be  punctured  and  pressed  upon, 
the  characteristic  clear  glairy  substance  will  be  extruded  and  the  induration 
will  largely  disappear.  In  fibromyoma  fibroids  elsewhere  in  the  uterus  may 
be  found,  making  it  probable  that  the  cervical  nodule  is  similar  in  nature.  A 
nodule  in  the  cervix  that  does  not  correspond  with  any  of  the  conditions  just 


272 


GYXECOLOGIC    DIAGNOSIS 


nientioned,  may  be  begimiiiig  malignant  disease.  A  j^iece  of  it  should  be 
excised  and  submitted  to  microscopic  examination,  to  establish  certainly  the 
diagnosis  at  a  time  when  a  diagnosis  %vill  do  some  good. 

Tenderness  of  the  Cervix  usually  means  inflammation  around  the  uterus. 
The  tissue  of  the  cervix  is  ordinarily  not  painful  to  pressure  even  when  dis- 
eased. The  tenderness  so  often  complained  of  when  pressure  is  made  on  the 
cervix,  is  usually  due  to  a  slight  involvement  around  the  uterus  and  consequent 
pulling  on  inflamed  periuterine  tissues  due  to  the  moving  of  the  uterus. 


Fig.   312.     Eversion   of  the   Cervical  Mucosa  due  to  inflammation  within  the  cervix.      (Cullen — Caticer 
of  the  Uterus.) 

There  has  been  no  laceration  of  the  cervix  in  this  case,  the  patient  being  a  Nullipara.  This  eversion 
of  the  cervical  mucosa  by  inflammation  only,  without  previous  laceration,  is  a  rare  condition.  It  is  likely 
to  lead  to  a  mistaken  diagnosis  of  laceration  of  the  cervix.  It  is  also  of  medico-legal  importance,  as  the 
appearance  of  laceration  ma}-  lead  to  the  erroneous  conclusion  that  the  patient  has  at  sometime  given  birth 
to  a  child. 


Fixation  of  the  Cervix  may  he  due  to  inflammatory  exudate,  to  a  tumor 
about  the  uterus  or  to  sear-tissue  in  the  upper  part  of  the  A'agina. 

Abnormal  Mobility  of  the  Cervix  is  due  to  stretching  of  the  supporting 
tissues  around  it  and  of  the  pelvic  floor  below  it. 


CHAXGES    IX    CERVIX    UTERI 


273 


Fig.   313.  Fig.   314. 

Figs.  313  and  314.     Side  and  Front  Views  o£  a  Simple  Bilateral  Laceration,  requiring  no  treatment. 


Fig.   313.     F'ront    view    of    a    Unilateral    Laceration 
requiring  no   treatment. 


Fig.  316.  Side  View  of  a  L'nilateral  Lacera- 
tion. Such  a  laceration  may  cause  abortion  in  the 
early    months    of    pregnancy. 


Fig.   317.      Side   View    of   a    Bilateral    Laceration,         Fig.   318.     Front    View    of    a    Bilateral     Laceration, 
requiring  treatment.     The  lips   are  everted,   and   the  showing  eroded   area   and   Xabothian   follicles. 

Xabothian   follicles   stand    out    as    small   hard  lumps. 

Figs.  313  to  318.     Lacerations  of  the  Cervix   Uteri.      (Tialdy-^Ainencan  Textbook  of  Gynecology.) 


Fig.  319.  Palpating  the  Cervix  to  Determine  Soft- 
ening. The  light  stippled  area  represents  the  softened 
portion.  The  uterus  is  represented  as  enlarged  from  early 
pregnancy. 


Fig.  320.  Section  of  the  Cervix,  in  preg- 
nancy at  term,  showing  that  the  cervix  is  still 
of  Full  Length.  The  sensation  of  shortening 
imparted  to  the  examining  finger  is  due  to  the 
softening,  causing  the  lower  part  to  be  not 
easily  appreciated  by  the  finger.  (Dickinson, 
after  \\'aldeycr — American  Textbook  of  Ob- 
stetrics.) 


274 


GYNECOLOGIC    DIAGNOSIS 


Fig.    321.     Beginning   Carcinoma   within   the    Cervix,   causing  a   Hard   Nodule    which    can   be    felt    on    digital 
examination.      (Kelly — Operative   Gyneeology.) 


f 


Fig.  322.  Cysts  of  the  Cervix.  These  fetl  like  Hard  Nodules  and  hence  may  lead  to  a  mistaken 
diagnosis  of  malignant  disease  in  the  cervix,  as  happened  in  the  case  from  which  this  specimen  was  taken. 
At  operation  the  carcinoma  (which  was  diagnosed  from  curettings)  was  found  to  be  confined  to  the  corpus 
uteri,  as  shown  in  the  specimen,  instead  of  extending  to  the  cervix  as  was  previously  supposed.  (Kelly — 
Operative  Gynecology.') 


VAGINO-ABDOMINAL   EXAMINATION  275 

MASS  FELT  IN  CERVICAL  CANAL 

On  palpating  the  cei'vix  some  one  of  the  following  small  masses  may  in 
some  cases  be  felt  just  within  the  external  os  or  projecting  slightly  from  it. 

Blood  Clot.  This  is  soft  and  easily  broken,  if  it  projects  far  enough  to 
permit  of  its  being  caught  between  the  fingers.  When  it  is  up  in  the  canal 
so  that  only  the  lower  edg€  or  end  can  be  felt,  it  may  feel  very  much  like  a 
piece  of  tissue.  Introduce  the  uterine  dressing  forceps  beside  the  finger  and 
catch  the  small  mass  and  bring  it  outside  for  inspection. 

Placental  Remnants.  In  incomplete  miscarriage  a  small  piece  of  tissue 
may  often  be  felt  in  the  cervical  canal,  showing  that  there  are  retained  rem- 
nants that  must  be  removed.  It  is  in  this  same  class  of  cases  that  a  firm  blood 
clot  in  the  cervix  may  lead  to  an  erroneous  diagnosis,  hence  the  importance  of 
removing  the  small  mass  Avith  a  forceps  so  that  it  may  be  examined  to  de- 
termine certainly  whether  it  is  a  piece  of  tissue  or  only  a  blood  clot.  To  de- 
termine if  it  has  the  bushy  projections  of  placental  tissue,  spread  it  out  in 
water.  If  it  is  of  doubtful  character,  submit  it  to  miscroscopic  examination. 
It  may  be  a  broken  off  papillary  mass  from  a  malignant  growth  in  the  uterus. 

Mucous  Polypus.  Mucous  polypi  are  frequently  found  projecting  from 
the  cervix  or  up  in  the  canal  (Chapter  vi.)  They  may  be  so  soft  as  to  be 
hardly  noticed  in  the  digital  examination  but,  when  projecting  from  the  canal, 
are  very  apparent  in  the  speculum  examination. 

Fibrinous  Polypus.  This  is  a  polypus  which  has  gradually  enlarged  from 
accretions  of  fibrin  about  a  placental .  remnant  or  other  small  mass  in  the 
uterine  cavity.    Its  character  is  determined  by  microscopic  examination. 

Fibroid  Polypus  (Fig.  288).  This  is  a  small  pediculated  submucous  fibroid, 
the  pedicle  of  which  has  become  stretched  sufficiently  to  permit  the  mass  to 
appear  at  the  external  os  or  to  project  from  the  same.  It  may  be  attached 
in  the  body  of  the  uterus  or  in  the  cervix,  usually  the  former. 

Malignant  Polypus.  A  malignant  growth  in  the  cervix  or  in  the  body  of 
the  uterus  may  send  out  a  papillary  projection  that  appears  at  the  external 
OS  as  a  polypus.  Again  malignant  change  may  be  present  in,  or  may  develop 
in,  apparently  simple  polypi.  For  this  reason  all  polypi  of  whatever  kind 
removed  from  the  cervix  should  be  preserved  that  their  exact  character  may 
be  determined  by  microscopic  examination. 

POINTS  IN  THE  VAGINO-ABDOMINAL  EXAMINATION 

CHANGES  IN  CORPUS  UTERI 

Backward  Displacement  of  the  Uterus  (Fig.  323).  The  body  of  the  uterus 
is  not  made  out  in  front  (Fig.  65).  In  the  back  part  of  the  pelvis  there  is  felt 
a  body,  apparently  continuous  with  the  cervix,  and  of  the  size,  shape  and 
consistency  of  the  corpus  uteri  (Figs.  66,  67).     It  may  be  movable  or  fixed, 


276 


GYNECOLOGIC    DIAGNOSIS 


tender  or  not  tender.  No  other  mass  is  felt  in  the  pelvis.  Siicli  a  mass  is  in 
all  probability  the  body  of  the  uterus  in  backward  displacement.  If  some  of 
Ihe  necessary  points  can  not  be  made  out  distinctly  and  there  are  circum- 
stances which  make  it  important  to  know  at  once  the  exact  location  of  the 
corpus  uteri,  this  may  l)e  determined  certainly  by  introducing  the  sound 
into  the  uterus.    But  do  not  use  the  sound  except  when  there  is  some  special 


Fig.   323.     Retrodisplacement  of  the  Uterus,  showing  the  first,  second  and  third  Degrees.      (Skene — Diseases 

of  Women.) 


VAGINA 
RECTUM 

Fig.  324.     Uterus     displaced    backward    by    a    Full        Fig.   325.     Uterus   displaced   laterally   by   an   Inflam- 
Bladder.      (Montgomery — Practical  Gynecology.)  matory  Mass.      (Edgar — Practice  of  Obstetrics.) 


CHANGES   IN"    CORPUS   UTERI 


277 


reason  for  doing  so,  and  remember  the  contraindications  to  sonnding  given 
in  Chapter  i. 

This  retrodisplacement  of  the  body  of  the  uterus  may  be  due  to  a  full 
bladder  (Fig.  324)  or  to  an  inflammatory  mass  in  the  front  part  of  the  pelvis 
or  to  a  tumor.  On  the  other  hand,  the  displacement  itself,  with  or  Avithout 
an  accompanying  inflammatoiy  trouble,  may  be  the  principal  lesion. 


Fig.  326.     Uterus  puslied  to  the  left  side  by  a  Tumor  or  Inflammatory  Mass  in  the  opposite  side.      (Findley- 

Diagnosis   of  Diseases   of    Wonen.) 


I'ig.  Z17.     Uterus  Drawn  to  the  left  side  by  Adhesions  or  Infiltration  in  the  same  side.      (Findley — Diaynosis 

of  Diseases  of  Women.) 


Forward  Displacement  of  the  Uterus.  ForAvard  displacement  of  the  body 
of  the  uterus  may  be  due  to  the  body  of  the  uterus  being  heavy  and  softened, 
as  in  early  pregnancy  (Fig.  328)  and  also  in  certain  inflammatory  conditions, 
or  to  an  inflammatory  mass  or  a  tumor  pushing  the  fundus  forward  and  down- 
ward. 


278 


GYNECOLOGIC   DIAGNOSIS 


Placenta 
Orif.  int.  uteri 

Orif.  ext.  uteri 


Excav.  lesicouter. 


Pa)'ies  recti 


Vesica  urin. 


V.  dorsalis  clitor.  " 


Clitorin 


Fornix 
vagin.  post. 


M.  sphincter 
ani  ext. 


funica  muscul.  recti 


M.  sphincter  ani  ext. 
Urethra 
Tunica  muscul.  urethr.  Vagina 


Fig    328.      Frozen  Section  of  a  body  showing  the  Uterus  Enlarged  from  early  Pregnancy.     Notice  the  sharp 
anteflexion  of  the  softened  uterus.      (Waldeyer— Das  Becken.) 


CHANGES    IN    CORPUS    UTERI 


279 


fig.   329.     Early   Pregnancy  with  Retrodisplacement   of  uterus.      (Edgar — Practice   of  Obstetrics.) 


Fig.   330.     Early    Pregnancy    with   a   more    marked    Rttrodisijlacement    of    the    uterus.      (Edgar — Practice    of 

Obstetrics.) 


280 


GYNECOLOGIC   DIAGNOSIS 


Lateral  Displacement  of  the  Uterus  may  be  caused  by  an  inflammatory 
mass  (Fig.  325)  or  by  a  blood  mass  (Fig.  363)  or  by  a  tumor  (Fig.  326),  push- 
ing the  uterus  toward  the  opposite  side.  It  may  be  due  also  to  old  adhesions 
drawing  the  uterus  to  the  side  (Fig.  327),  or  it  may  be  due  simply  to 
a  heavy  uterus  leaning  to  the  side. 

Slight  Enlargement  of  the  Uterus  may  be  caused  by  early  pregnancy. 
There  is  usually  decided  anteflexion  of  the  softened  uterus  in  this  early  stage 
(Fig.  348).  Occasionally  there  is  backw^ard  displacement  of  the  pregnant 
uterus  (Figs.  329,  330).  From  about  the  sixth  to  the  twelfth  week  there  is  a 
peculiar  softening  and  compressibility  of  the  lower  portion  of  the  body 
of  the  uterus  which  contrasts  markedly  with  the  less  compressible  portion 
above.     This  is  known  as  Hegar's  sign,  and  when  well  marked  is  a  strong 


•"-v-^ 


Fig.   331.     A   Sectioned   Uterus   in   early    Pregnancy,   showing   the   two    halves   and   the   interior   arrangement 
which  gives  Hegar's  Sign.     (Edgar,   after  Pinard — Practice  of  Obstetrics.) 


indication  of  early  pregnancy.  Fig.  331  sIioavs  the  section  of  a  uterus  in  early 
pregnancy.  Fig.  332  explains  the  sensation  imparted  to  the  examining  flnger. 
The  examination  may  be  made  in  the  usual  Avay,  with  the  abdominal  fingers 
back  of  the  uterus  (Fig.  333),  or  the  abdominal  fingers  may  be  pressed  in 
front  of  the  fundus  uteri,  which  is  displaced  somewhat  backward,  while  the 
vaginal  fingers  are  placed  behind  the  uterus  (Fig.  334). 

Slight  enlargement  of  the  uterus  may  be  due  also  to  tubal  pregnancy  or 
to  chronic  inflammation  or  to  one  or  more  fibroid  tumors  (Figs.  335,  336,  337, 
338)  or  to  carcinoma  of  the  corpus  uteri  (Fig.  339)  or  to  sarcoma  or  to  lipoma 
or  to  pyometra  (Fig.  358)  or  to  tuberculosis  of  the  uterus  (Chapter  vi). 


CHANGES   IN    CORPUS    UTERI 


281 


Marked  Enlargement  of  the  Uterus  may  be  due  to  normal  pregnancy 
(Flg-s.  340,  341,  342).  Fig.  343  shows  the  height  of  the  fundus  at  the  various 
weeks  of  a  normal  pregnancy.  Bear  in  mind  that  the  pregnant  uterus  is  not 
always  regular  in  shape,  but  is  occasionally  quite  irregular  (Figs.  344,  345, 
346).  Enlargement  may  be  due  also  to  a  pregnancy  somewhat  abnormal,  for 
example,  presenting  backward  displacement  or  hydramnios  or  hydatidiform 
mole  or  hematom-mole.     Again,  marked  enlargement  of  the  uterus  may  be 


ssT^^e. 


Fig.  332.  Showing  the  Sensations  imparted 
to  the  examining  fingers  by  different  portions  of 
the  uterus  in  Early  Pregnancy,  particularly  the 
marked  Compressibility  of  the  portion  just  above 
the  internal  os  (Hegar's  Sign).  (Dickinson — - 
American    Textbook    of    Obstetrics.) 


Fig.  333.  Palpating  for  Hegar's  Sign,  with 
the  uterus  forward  in  the  usual  position.  (Edgar 
— Practice   of   Obstetrics.) 


Fig.  334.  Palpating  for  Hegar's  Sign,  with  the 
fundus  uteri  pushed  backward,  the  abdominal  fingers 
being  in  front  and  the  vaginal  fingers  back  of  the  cer- 
vix.    (Williams — Obstetrics.) 


caused  by  interstitial  pregnancy  (Fig.  347)  or  by  pregnancy  in  a  septate  uterus 

(Fig.  348). 

Aside  from  pregnancy,  the  usual  causes  of  marked  enlargement  of  the 
corpus  uteri  are  fibromyomata  (Figs.  349,  350,  351,  352,  353)  and  malignant 
disease  (Fig.  354). 

In  some  cases  there  is  an  association  of  fibroid  and  pregnancy  (Figs.  355, 
356)  or  of  malignant  disease  and  pregnancy. 


282 


GYNECOLOGIC    DIAGNOSIS 


In  rare  instances  the  uterus  has  become  enlarged  from  menstrual  blood 
retained  because  of  atresia  of  the  cervix  (hematometra,  Fig.  357)  or  from  a 
collection  of  pus  (pyometra)  or  of  pus  and  gas  (pyophysometra,  Fig.  358). 

Softening'  of  the  Corpus  Uteri  is  caused  by  the  various  forms  of  intra- 
uterine pregnancy.  In  most  cases  of  early  pregnancy  the  characteristic  com- 
pressibility of  a  portion  of  the  uterus  (Hegar's  sign)  may  be  made  out,  and 


=^ 

i 

^  = 

--t' 

:   1 

'  , 

4 

^\\ 

/ 

f 

V 

■" "     / 

\ 

I 

^-"^ 

Fig.  335.  Hard  Nodiiles  in  the  Corpus  Uteri, 
due  to  small  Fibromyomata.  (Montgomery — Prac- 
tical Gynecology.) 


.Fig.  336.  Larger  Fibromyomata,  in  various  sit- 
uations in  the  uterine  wall.  (Schaeffer — Hand-Atlas 
of  Gynecology.) 


Fig.   337.     Other  varieties  of  Fibromyomata,   giving  rise  to  a  diffuse   and   more   uniform   enlargement   of  the 
uterus.     (Montgomery — Practical  Gynecology.) 


CHANGES   IN    CORPUS    UTERI 


283 


Fig.  338.     A  Single  Fibroid  in  the  posterior  wall  of  the  uterus.      (Byford — Manual  of  Gynecology.) 


v'irC' 


Fig.  339.     Slight  Enlargement  of  the  Corpus  Uteri  caused  by  Carcinoma.     (Cullen — Cancer  of  the  Uterus.) 


284 


GYNECOLOGIC   DIAGNOSIS 


Fig.   340.     Pregnancy,    about  four   months.      (Edgar — Practice   of   Obstetrics.) 


t  .'V 


Fig.   341.     Pregnancy,  about   five  months.      (Edgar —  Fig.   342.      Pregnancy   at    Full   Term.      (Edgar- 

Practice    of    Obstetrics.)  Practice    of    Obstetrics.) 


CHANGES    IN    CORPUS    UTERI 


285 


when  well  mai'ked  is  of  much  assistance  in  differential  diagnosis.  Softening 
of  the  corpus  uteri  may  be  caused  also  by  extrauterine  pregnancy  and  like- 
wise by  a  recent  pregnancy  (i.e.,  for  a  few  weeks  following  labor  or  miscav- 
I'iage).  It  is  caused  also  by  edema  of  the  uterine  wall,  from  adjacent  inflam- 
mation or  from  a  tumor  interfering  with  the  circulation  or  from  marked  dis- 
placement. 


Fig.   343.     The    Height    of    the    Fundus    Uteri    at    various    weeks    of    Pregnancy.       (Williams — Obstetrics.) 


Figs. 


Fig.  344. 
344,  345,   and  346. 


Fig.   345. 


Fig.  346. 


Irregular   Shapes   that   Pregnant  Uteri   may   present,    and   which    may   lead 
takes   in  diagnosis.      (Edgar — Practice   of  Obstetrics.) 


286 


GYXECOLOGIC    DIAGNOSIS 


yratir-- 


Amruon 


Uterine  cavily 


C  ervi>; .  - 


Partially  separate; 


placenta. 


Fig.    347.     Interstitial    Pregnancy.       (Williams,    after    Bumm — Obstetrics.) 


Fig.  348.     Pregnancy  in  the   Right   Half   of  a   Septate   Uterus.      (KeWy— Operative   Gynecology.) 


CHANGES   IN    CORPUS   UTERI 


287 


Fig.   349.     Uterus   Enlarged  by   a   large   soft   single    Fibroid.      (Bishop — Uterine   Pibromyomata.) 


288 


GYNECOLOGIC   DIAGNOSIS 


Hard  Nodules  Felt  in  the  Corpus  Uteri  may  be  due  to  parts  of  the  child 
ill  pregnancy  or  to  fibromyomata  or  to  a  malignant  tumor.  In  rare  cases  an 
atheromatous  or  sclerotic  process  may  cause  hardening  of  areas  appreciable 
to  the  finger.    Also,  a  mass  of  exudate  or  some  adherent  structure  may  cause 


Fig.   350.     Uterus    Symmetrically   Enlarged   from  Fibroids.      This   might   be   mistaken  for   a  pregnant   tlterus, 
on  account  of  the  close  resemblance   in  shape.      (Kelly — Operative   Gynecology.) 


Fig.   351.      Subperitoneal    Fibroids,    showing   the    irregularity    and    distortion    often    present. 
(Kelly — Operative    Gynecology.) 


a  hard  mass  that  appears,   on  bimanual  examination,   to   be   a   part  of  the 
uterus. 

Marked  Tenderness  of  the  Uterus  may  be  caused  by  inflammation  of  the 
uterus,  by  inflammation  around  the  uterus,  by  hemorrhage  around  the  uterus, 
by  pelvic  neuralgia  or  by  functional  hyperesthesia  (hysteria,  neurasthenia). 


CHANGES   IN    CORPUS   UTERI 


289 


Fig.   352.      Single   Large   Fibroid  in  anterior  uter-  Fig.   353.     Large   Fibroids,    filling   the    pelvis   and 

ine    wall,    choking    the    pelvis.        (Kelly — Operative       lower  abdomen.     (A.  Martin — Atlas  of  Gynecology.) 
Gynecology.) 


Fig.   354.     Uterus  Enlarged  from  Carcinoma.    The  Fig.   355.     Fibroid     Tumor    and     Pregnancy,     the 

interior  of  the  uterus  is  occupied  by  the  growth  and  tumor    forming    the    most    of   the    mass.       (Dudley — 

it   has    extended   through,    forming  some   nodules    on  Practice  of  Gynecology.) 
the  outer  surface.     (Kelly — Operative  Gynecology.) 


290 


GYNECOLOGIC   DIAGNOSIS 


Fixation  of  the  Uterus  may  be  due  to  an  inflammatory  mass,  to  a  hemoi-- 
rhagic  mass,  to  old  adhesions,  to  a  new  growth  or  to  scar-tissue  from  vaginal 
laceration. 

Abnormal  Mobility  of  the  Uterus  is  due  to  overstretching  of  the  supports 
around  it  and  of  the  pelvic  floor  below  it. 


Fig.   356.     Fibroid    Tumor     and     Pregnancy,     the  Fig.   357.     Uterus  distended  with  Menstrual  Blood- 
pregnancy    forming    the    larger    part    of    the    mass.  (Hematoraetra),  due  to  atresia  of  the  cervix.     (Mont- 
(Norris,      after     Simpson — American      Textbook      of  gomery — Practical   Gynecology.) 
Obstetrics.) 


Fig.   358.     Uterus,  enlarged  by  a  collection  of  Pus  and  Gas   (Pyophysometra)    above   an  occluded   cancerous 

cervix.      {Kelly—Operative   Gynecology.) 


MASS   OR   INDURATION   IN   PELVIS 


291 


MASS   OR  INDURATION 
In  Pelvis  or  Lower  Abdomen,  Felt  on  Bimanual  Examination 

MASS  LOW  IN  PELVIS,  AND   TO  RIGHT   OF   CERVIX 

A.  Mass  or  Induration  Firm  (No  Fluid  Felt) 

1.  Body  of  the  Uterus  Displaced  to  the  Right.  The  mass  is  directly  con- 
tinuous with  the  cervix  and  is  about  tlie  size  and  shape  of  the  body  of  the 
uterus.  The  uterus  can  not  be  felt  elsewhere.  If  not  adherent  or  very  tender, 
it  may  be  pushed  back  to  the  normal  position  of  the  corpus  uteri.  The  uterus 
may  lie  somewhat  to  one  side,  though  freely  movable,  or  it  may  be  drawn  to 
one  side  by  adhesions,  or  it  may  be  pushed  over  by  a  tumor  or  an  inflammatory 
mass  or  a  blood  mass. 

The  displaced  uterus  may  be  of  a  normal  size  or  it  may  be  enlarged.  If 
enlarged,  it  may  be  of  regular  shape   or  distorted.     It  may  be   of  normal 


Fig.  359.  The  Three  Spaces  or  Areas  in  the 
Pelvis.  A.  Peritoneal  Cavity.  B.  Subperitoneal 
connective  tissue  area  or  Parametrial  Space.  C. 
Ischio-rectal  Space.  The  white  line  betvi^een  B  and 
C  represents  the  levator  ani  muscle.  (Dudley — 
Practice   of   Gynecology.) 


Fig.  360.  On  the  right  is  a  large  inflamma- 
tory mass  in  the  Parametrial  Space.  This  is  what 
is   meant   ordinarily   by  the  term   Pelvic    Cellulitis. 

On  the  left  is  a  small  inflammatory  mass  in  the 
Ischio-rectal  Space.  From  inflammatory  trouble  in 
this  region  comes  the  well  known  Ischio-rectal  Ab- 
scess.      (Dudley — Practice    of    Gynecology.) 


consistency  or  softened  or  presenting  hard  nodules.  If  there  is  inflammation 
in  the  uterus  or  around  it,  it  may  present  decided  tenderness.  Whether  it  is 
movable  or  fixed  depends  on  the  cause  of  the  displacement.  If  there  is  attach- 
ment by  adhesions  to  the  pelvic  wall  or  to  an  inflammatory  mass  or  to  a  tumor, 
determine  whether  it  is  at  the  lower  or  upper  part  of  the  uterus. 

2.  Salpingitis  Vidth  Exudate,  extending  to  the  side  of  the  cul-de-sac.  The 
inflamed  tube  itself  is  situated  higher,  but  some  fibrinous  peritoneal  exudate 
has  extended  down  so  that  it  is  felt  to  the  right  side  of  the  cervix  posteriorly. 

3.  Salpingitis  with  Prolapse  of  Thickened  Tube.  The  enlarged  and  in- 
durated tube  may  be  movable,  or  it  may  be  bound  in  its  abnormal  situation  by 
adhesions. 


292 


GYNECOLOGIC    DIAGNOSIS 


4.  Salpingitis  with  Secondary  Infiltration  of  the  connective  tissue  about 
the  cervix.  This  presents  practically  the  same  signs  low  in  the  pelvis  as  a 
primary  cellulitis,  but  in  addition  there  is  felt  higher,  the  mass  formed  by 
thickened  tube  and  peritoneal  exudate. 

5.  Oophoritis  with  Prolapse  of  Ovary.  The  ovary  is  usually  enlarged  and 
cystic,  but  none  of  the  cysts  are  yet  large  enough  to  give  distinct  fluctuation. 
Ordinarily,  the  ovary  feels  much  softer  on  palpation  than  either  an  infiltrated 
tube  or  a  mass  of  exudate.  This  softness  may  be  so  marked  as  to  lead  to  the 
erroneous  idea  that  fluctuation  (a  well  marked  cyst)  is  present,  while  in  fact 
the  ovarian  tissue  may  be  practically  normal.  The  chronically  inflamed  ovary 
is  occasionally  as  firm  as  other  tissue  which  is  the  seat  of  inflammatory  infiltra- 


Fig.  361.  Mass  in  Right  Ureter.  It  is  a  Calculus  of  enormous  size,  situated  in  the  ureter  and 
extending  into  the  bladder  wall;  a,  calculus;  h,  upper  part  of  right  ureter  (thickened);  c,  left  ureter; 
d,  sigmoid;   e,  left  Fallopian  tube;  /,  bladder  pushed  to  one  side.      (Bovee — Practice  of  Gynecology.) 


tion.  This  is  the  case  particularly  in  the  cirrhotic  ovary,  which  is  also  usually 
smaller  than  the  normal  ovary. 

The  fact  that  the  mass,  felt  to  the  right  of  the  cervix  posteriorly,  is  the 
ovary,  is  determined  by  noticing  its  position,  size,  shape,  consistency,  tender- 
ness, mobility  and  point  of  attachment.  The  ovary  is  usually  decidedly  tender, 
even  when  normal,  and  pressure  upon  it  produces  a  peculiar  sickening  pain. 

One  of  the  characteristics  of  the  prolapsed  ovary,  when  not  adherent,  is 
that  it  is  freely  movable.     It  slips  away  from  the  examining  finger  and  may 


MASS    OR    INDURATION    IN   PELVIS 


293 


1)6  pushed  up  out  of  the  lower  part  of  the  pelvis.  Following  the  mass  up  and 
making  deep  bimanual  palpation,  its  point  of  attachment  is  found  to  be  in  the 
tubo-ovarian  region.  If  there  has  been  any  peritoneal  exudate,  the  ovary  is 
likely  to  be  fixed  in  its  abnormal  position  by  adhesions. 

6.  Small  Abscess  from  any  of  the  above  conditions,  near  the  posterior 
lateral  part  of  the  cervix  and  with  such  a  thickened  wall  that  no  fluctuation 


Fig.   362.     Mass    beside    Uterus,    formed    by    Abscess    in    broad    ligament.       (Montgomery — 

Practical   Gynecology.) 

is  obtained.  There  is  a  point  of  marked  tenderness,  with  fixation  of  the  tis- 
sues in  the  vicinity.  If  of  recent  origin  there  will  be  some  fever,  but  in  an 
old  abscess  the  temperature  may  be  practically  normal.  The  history  of  the 
trouble  and  the  findings  elsewhere  in  the  pelvis  will  indicate  the  character 
of  the  primary  lesion. 


Fig.   363.     Hematoma    of    Right    Broad    Ligament.       (Montgomery — Practical    Gynecology.) 

7.  Adhesions  at  the  side  of  the  cervix  from  any  of  the  above  affections. 
In  the  absence  of  pus  or  active  infiammation,  there  is  usually  not  much 
tenderness.  The  principal  signs  are  induration,  without  a  definitely-outlined 
mass,  and  fixation. 


294 


GYNECOLOGIC   DIAGNOSIS 


8.  Cellulitis.  This  may  be  acute  or  subacute.  The  induration  is  situated 
very  low  and  blends  with  the  cervix.  It  may  be  a  small  mass  or  may  fill  all 
that  side  of  the  pelvis,  extending  out  to  the  pelvic  wall.  As  a  rule  its  shape 
corresponds  approximately  with  the  connective  areas  (Fig.  359).  If  the  in- 
flammation is  in  the  parametrium  (above  the  levator  ani),  it  is  immediately 
about  the  cervix  (Fig.  360).  If  it  is  below  the  levator  ani,  in  the  ischio-rectal 
space,  the  induration  will  be  lower,  along  the  vaginal  wall  and  rectum,  and 
there  will  be  induration  near  the  anus.  In  jDelvic  cellulitis,  except  in  the 
acute  cases,  the  induration  feels  exceptionally  hard,  possibly  because  there  is 
but  little  intervening  soft  tissue  between  the  examining  finger  and  the  infiltra- 
tion. The  hardness  is  so  marked  in  some  cases  as  to  give  the  impression  of  a 
cartilaginous  growth  from  the  pelvic  wall.  The  uterine  attachment  of  the 
mass  is  low,  principally  about  the  cervix.  The  outer  extremity  extends  to 
the  pelvic  wall,  where  it  is  intimately  attached  over  a  broad  surface  (Fig. 
360). 


Fig.   364.     A    Parovarian    Cyst,    forming    a    large   Mass    and   displacing    the    uterus. 

Pi-actice    of    Gynecology.) 


(Ashton- 


9.  Small  Abscess  from  Cellulitis,  with  wall  so  thick  that  no  fluctuation  is 
obtained.  There  is  a  point  of  marked  tenderness,  with  some  fever,  and  u 
mass  of  induration  presenting  the  characteristics  of  cellulitis. 

10.  Scar-Tissue  from  Former  Cellulitis.  As  explained  elsewhere,  uncom- 
plicated cellulitis,  like  other  forms  of  lymphangitis,  runs  its  course  and  ends 
in  resolution  or  abscess  formation  with  discharge  of  the  pus.  In  either  case 
the  accompanying  inflammatory  infiltration  eventuates  in  the  formation  of 
new  connective  tissue  which  contracts  like  other  scar-tissue,  causing  persist- 
ent induration  and  fixation  of  tissues  in  the  affected  area.  There  is  not  much 
tenderness  from  the  scar-tissue  itself,  but  the  resulting  compression  or  con- 
striction of  nerves  and  interference  with  the  circulation  liy  distortion,  may 
exceptionally  cause  persistent  tenderness  and  pain. 

11.  Scar-Tissue  from  Laceration  in  Labor.     Not  infrequently  tears  of  the 


MASS    OR    INDURATION   IN   PELVIS 


295 


cervix  are  so  extensive  that  they  involve  the  vaginal  wall  and  the  parametrium, 
giving  scars  that  may  be  felt  beside  the  cervix.  The  induration  may  bo  linear 
or  vs^idespread.  The  fixation  of  the  cervix  may  be  slight  or  marked,  depending 
on  the  amount  and  situation  of  the  scar-tissue.  Usually  there  is  not  much 
tenderness. 

12.  Malignant  Infiltration  of  the  parametrium,  extending  from  the  cervix 
uteri  or  the  bladder  or  the  rectum.  The  induration  is  firm  and  is  situated  im- 
mediately beneath  the  vaginal  wall  and  usually  follows  approximately  the 
outline  of  the  connective  area.  Ordinarily  there  is  not  much  tenderness,  un- 
less there  is  complicating  inflammation.  The  amount  of  fixation  of  the  cervix 
depends  on  the  extent  of  the  infiltration. 

13.  Fibroid  of  Uterus,  growing  into  right  broad  ligament.  The  mass  pro- 
jects out  from  the  side  of  the  uterus,  has  a  rounded  well-defined  outer  border 
and  is  firm  and  not  tender.  The  mass  is  fixed  by  a  broad  attachment  to  the 
side  of  the  uterus  but  the  uterus  and  mass  together  are  movable  in  the  pelvis, 


Fig.   365.     An    Ovarian    Cyst    growing   in    beside    the   uterus.      (Montgomery — Practical    Gynecology.) 


unless  the  mass  is  so  large  that  it  extends  to  the  pelvic  wall  or  there  is  com- 
plicating infiammatory  fixation. 

14.  Affection  of  Right  Ureter.  A  mass  about  the  ureter  may  be  caused  by 
inflammation  in  and  around  the  ureter.  The  inflammation  may  be  due  to  a 
stone  lodged  in  the  ureter  or  to  tubercular  ureteritis  or  to  an  ascending  pus 
infection.  The  mass  is  situated  in  the  course  of  the  ureter,  is  small  at  first  and 
may  give  the  impression  of  a  small  nodule  like  an  enlarged  gland  in  the  tis- 
sues. It  is  firm,  very  tender,  fixed,  but  not  intimately  attached  to  any  of 
the  adjacent  organs  until  extensive  infiltration  has  formed.  Fig.  361  shows  a 
mass  from  the  right  ureter.  A  mass  from  the  ureter  is  accompanied  by  blad- 
der irritability  and  urinary  abnormalities. 

15.  Solid  Tumor  of  Ovary  or  Tube,  bound  down  by  adhesions  and  forced 
to  grow  towards  the  cervix.  The  mass  would  necessarily  become  of  consider- 
able size  before  reaching  that  region.  It  is  approximately  spherical,  though 
of  somewhat  irregular  outline.     It  is  firm  and  usually  somewhat  tender  be- 


296 


GTXECOLOGIC    DIAGNOSIS 


cause  of  the  aecompanving  inflammation,  but  not  as  tender  as  an  inflamma- 
tory mass  of  the  same  size  would  be.  It  is  fixed  in  the  pelvis  and  attached 
to  all  surrounding  structures.  The  uterus  is  usually  pushed  far  to  the  op- 
posite side,  but  the  history  does  not  show  the  severe  disturbance  that  would 
necessarily  accompany  a  purely  inflanmiatory  mass  of  like  size. 

B.  Mass  Contains  Fluid  (Fluctuation  May  be  Obtamed) 

1.  Pelvic  Abscess  (Fig.  362)  from  salpingitis,  with  secondary  involvement 
of  connective  tissue;  or  from  primary  cellulitis;  or  from  suppuration  in  a 
fibroid  tumor,  in  a  cyst  or  in  a  hematoma  in  this  situation.  The  mass 
usually  fills  in  all  the  lower  part  of  that  side  of  the  pelvis,  and  is  surrounded 


VULI/A. 


Fig.   366.     Hematometra    in    a    Rudimentary    Horn    of    the    Uterus.       (Montgomer}- — Practical    Gynecology.) 

by  infiltration  which  shades  off  gradually  into  the  surrounding  tissues.  The 
area  of  fluctuation  is  surrounded  by  induration.  There  is  marked  tenderness 
at  the  point  of  fluctuation,  which  diminishes  usually  as  the  periphery  of  the 
mass  is  reached.  There  is  fixation  of  all  the  involved  tissues  and  of  the  adja- 
cent organs,  including  the  uterus.  The  history  and  the  findings  elsewhere 
in  the  pelvis,  indicate  the  seat  of  the  primary  inflammation. 

2.  Pelvic  Hematoma  (Fig.  363).  This  usually  comes  from  a  tubal  preg- 
nancy, which  has  ruptured  between  the  layers  of  the  broad  ligament.  The 
induration  runs  down  close  around  the  cervix,  and  may  be  small  or  may  fill 
all  that  side  of  the  pelvis  extending  up  to  the  ti)p  of  the  broad  ligament.  It 
has    a    general   rounded    outline,    much    more   so    generally    than    an    inflam- 


MASS    OR   INDURATION   IN   PELVIS 


297 


matory  infiltration  in  the  connective  tissue,  tliougli  it  is  limited  anteriorly  and 
posteriorly  by  the  separated  peritoneal  layers  of  the  broad  ligament. 

It  is  largely  fluid  and  there  is  distinct  fluctuation  over  a  considerable 
area,  as  in  a  cyst.  Also,  there  is  not  so  much  surrounding  induration  as  in  an 
abscess,  though  usually  considerably  more  than  in  a  cyst.  The  tenderness  is 
not  nearly  so  marked  as  in  a  collection  of  blood  in  the  peritoneal  cavity.  Of 
course  the  tenderness  varies  somewhat,  being  more  marked  when  the  hemor- 
rhage is  recent  and  extensive,  in  which  case  it  may  be  very  marked.  Ordi- 
narily the  tenderness  from  a  hematoma  is  not  nearly  so  marked  as  tender- 
ness from  an  abscess.  There  is  fixation  of  the  mass  in  the  situation  in  which 
it  is  found,  and,  if  extensive,  it  fixes  the  uterus  to  the  pelvic  w^all.  The  history 
and  the  findings  elsewhere  will  show  the  cause  of  the  trouble. 

3.  Hydrosalpinx  coming  low  in  the  pelvis.     The  cystic  mass  runs  up  into 


Fig.   367.     Thickened    Tube    and    Ovary    prolapsed    into    the    cul-de-sac    behind    the    uterus. 
(Montgomery — Practical    Gynecology.) 

the  tubal  region.  It  is  somewhat  elongated  and  sausage-shaped  and  extends 
from  the  upper  angle  of  the  uterus  to  the  pelvic  wall.  It  fluctuates  freely  and 
gives  the  impression  of  a  thin-walled  cyst.  Frequently  some  induration  from 
exudate  or  adhesions,  may  be  felt.  It  is  not  tender  ordinarily.  It  is  somewhat 
movable,  though  not  as  much  so  as  a  small  pediculated  ovarian  tumor.  It  is 
attached  to  the  uterus  and  to  the  pelvic  wall  and  along  the  upper  part  of 
the  broad  ligament. 

4.  Parovarian  Cyst  (Fig.  364).  It  is  situated  near  the  center  of  the 
broad  ligament  and,  if  as  large  as  an  orange,  it  begins  to  come  down  about 
the  cervix  just  beneath  the  vaginal  wall.  It  is  approximately  spherical, 
though  somcAvhat  irregular  in  shape.  It  fluctuates  freely  throughout  and  the 
fluid  seems  very  close  to  the  examining  flngers.  There  is  no  tenderness,  unless 
complicated  by  inflammation  or  neuritis  or  other  painful  aifection. 

It  is  flxed,  as  a  rule,  but  not  firmly.     The  peritoneal  layers  of  the  broad 


298 


GYNECOLOGIC   DIAGNOSIS 


ligament  stretch  sufficiently  to  permit  considerable  movement  in  some  cases, 
especially  later,  when  the  cyst  has  become  so  large  that  it  rises  out  of  the 
pelvis.  The  uterus  is  displaced  to  the  opposite  side,  and  the  cyst  is  attached 
to  it  and  to  the  pelvic  wall,  but  not  intimately  as  a  rule.  If  inflammation  takes 
place  about  the  cyst  then  there  is  marked  fixation  and  attachment  to  all  adja- 
cent organs,  and  the  cyst  as  it  grows  may  elongate  the  body  of  the  uterus. 

5.  Ovarian  Cyst  growing  toward  the  cervix  (Fig.  365).  An  ovarian 
cyst  which  has  been  fixed  in  the  pelvis  by  inflammation  may  grow  in  this 
direction.  It  presents  the  same  characteristics  as  a  parovarian  cyst  compli- 
cated by  inflammation,  except  that  fluctuation  is  not  so  uniform  throughout 
the  mass.  There  may  be  firm  portions  representing  thick  septa  or  small  areolar 
cysts. 

6.  Cystic  Fibroid.  This  presents  the  ordinary  characteristics  of  a  fibroid, 
except  that  there  is  a  point  of  fluctuation  and  there  may  be  some  tenderness. 


Kig.  36S.  A  Fibroid  Tumor,  forming  a  Mass 
behind  the  uterus.  (Montgomery — Practical  Gyne- 
cology.) 


Fig.  369.  A  Retroflexed  Uterus  and  a  Fibroid, 
forming  a  Mass  behind  the  cervix.  (Montgomery — 
Practical    Gynecology.) 


7.  Uterus  Containing'  Fluid  and  displaced  to  one  side.  This  fluid  in  the 
uterus  may  be  due  to  pregnancy,  normal  or  abnormal,  or  to  a  cystic  fibroid  or 
to  pus  in  the  uterus  or  to  blood  in  the  uterus. 

8.  Rudimentary  Horn  of  Uterus,  containing  blood  (Fig.  366)  or  other 
fluid.    There  may  be  pregnancy  in  such  a  horn  (Fig.  385). 

9.  Vaginal  Cyst.  Vaginal  cysts  may  come  from  remnants  of  the  Wolffian 
duct  or  from  aberrant  gland  structures '  in  the  vaginal  wall.  They  protrude 
into  the  vagina  more  or  less,  are  small  and  rounded,  have  fluctuation  through- 
out with  a  thin  wall  and  are  not  tender  unless  complicated.  They  are  fixed 
in  the  lower  part  of  the  pelvis  and  lie  just  beneath  the  vaginal  wall,  to  which 
they  are'  closely  attached. 

10.  Ureter  Greatly  Dilated.  The  fluid  in  the  dilated  ureter  may  be  urine 
(hydro-ureter)  or  pus  (pyo-ureter).  The  upper  part  of  the  ureter  and  the 
kidney  is  usually  dilated  also  (hydronephrosis,  pyonephrosis).     A  fluctuating 


MASS   LOW   AND    BEHIND    CERVIX 


299 


swelling  is  found  in  the  region  of  the  ureter,  accompanied  by  symptoms  of 
bladder  irritation  and  urinary  evidences  of  disease.  The  retained  urine  may 
be  discharged  at  times  through  the  bladder.  The  swelling  then  largely  disap- 
pears, to  reappear  when  the  obstruction  again  occurs  and  the  sac  refills.  A 
careful  investigation  as  to  the  amount  and  character  of  the  urine  discharged 
with  the  variation  in  the  size  of  the  mass,  is  an  important  step  in  the  diag- 
nosis of  such  a  mass. 


MASS  LOW  IN  PELVIS,  AND  TO  LEFT  OF  CERVIX 

A.  Mass  or  Induration  Firm  (No  fluid  felt).    Same  as  on  right  side. 

B.  Mass  contains  Fluid  (Fluctuation  obtained).     Same  as  on  right  side. 

MASS  LOW  AND  BEHIND  CERVIX 
A.  Mass  or  Induration  Firm 

1.  Body  of  Uterus  Displaced  backward  to  the  3rd  degree  (Fig.  67).  Any 
of  the  various  solid  conditions  of  the  uterus  previously  mentioned  may  be 
present. 

2.  Salpingitis  with  Exudate  extending  into  the  cul-de-sac. 


Fig.   370.     An    Abscess  behind    the    uterus, 
gomery — Practical    Gynecology.) 


(Mont- 


Fig.  371.  A  Blood  Mass  filling  the  pelvis  and 
running  down  behind  the  uterus.  (Montgomery — • 
Practical'  Gynecology.) 


3.  Salpingitis  with  Prolapse   of  the   thickened  tube  into   the   cul-de-sac 
(Fig.  367).     The  prolapsed  tube  may  be  movable  or  adherent. 

4.  Salpingitis  with  Secondary  Infiltration  of  the  connective  tissue  back 
of  the  uterus. 

5.  Oophoritis  with  Prolapse  of  the  ovary.     The  prolapsed  ovary  may  be 


300 


GYNECOLOGIC   DIAGNOSIS 


movable  or  adherent.    Tlie  characteristic  palpation  signs  of  a  prolapsed  ovary 
have  already  been  given. 

6.  Small  Abscess  behind  the  cervix,  from  any  of  the  above  conditions  and 
with  such  a  thick  wall  that  no  fluctuation  is  obtained. 

7.  Adhesions  behind  the  cervix,  from  any  of  the  above  affections. 

8.  Cellulitis.  For  the  characteristic  palpation  signs  of  cellulitis,  see  under 
Mass  to  Eight  of  Cervix. 

9.  Small  Abscess  from  Cellulitis,  with  wall  so  thick  that  no  fluctuation  is 
obtained. 

10.  Scar-Tissue  from  Former  Cellulitis.  This  is  not  nearly  so  frequent  in 
th's  region  as  peritoneal  adhesions. 

11.  Scar-Tissue  from  Laceration  in  Labor.  This  is  found  occasionally, 
though  it  is  rare  in  this  situation.  ]\tost  of  the  deep  lacerations  extend 
laterally. 


Fig.  372.     An  Ovarian  Cyst  lying  back  of  the  uterus.      (Ashton— Practice  of  Gynecology.) 

12.  Malignant  Infiltration  from  cancer  of  cervix  uteri  or  from  cancer  of 
the  rectum  or  from  cancer  of  the  bladder. 

13.  Fibroid  of  the  Uterus  growing  posteriorly  from  the  cervix  or  lower 
part  of  the  corpus  uteri  (Figs.  368,  369). 

14.  Affection  of  Ureter  with  exudate  extending  back  of  the  uterus.  The 
differential  diagnostic  points  of  a  ureteral  mass  have  already  been  given. 

15.  Solid  Tumor  of  Ovary  or  Tube,  forced  to  grow  into  the  cul-de-sac. 

16.  Fecal  Mass  in  Rectum.  Along  the  lower  part  of  the  posterior  vaginal 
wall  such  masses  cause  no  trouble  in  diagnosis,  but  in  the  region  of  the  cul- 
de-sac  they  may  lead  to  a  mistake.  The  characteristics  of  such  a  fecal  mass 
are  that  it  is  situated  in  the  course  of  the  rectum,  that  it  is  not  particularly 
tender,  that  it  is  of  putty-like  consistency  and  may  be  indented  (the  dent  re- 
maining) and  that  it  may  be  moved  along  to  another  position  in  the  canal. 


MASS   LOW    AND    BEHIND    CERVIX 


301 


If  there  is  still  doubt,  direct  the  patient  to  take  a  purgative  to  give  a  good 
boAvel  movement  and  the  next  day  an  enema  to  clear  out  the  large  bowel,  and 
then  return  for  another  examination. 

17.  Tumor  of  Rectum.  The  mass  is  in  the  wall  of  the  rectum  and  there 
are  usually  symptoms  of  rectal  irritation,  ^\dth  the  passage  of  blood  and  mucus. 

18.  An  Abdominal  Organ  Prolapsed  into  the  cul-de-sac.  A  wandering 
kidney  or  spleen  may  be  found  in  this  situation.  It  may  be  movable  or  fixed. 
It  presents  somewhat  the  characteristics  of  the  organ  involved,  i.e.,  it  has 
about  the  size,  shape,  consistency  and  tenderness.  If  movable,  it  may  be 
pushed  back  into  the  normal  situation  of  the  organ.  An  examination  in  the 
Trendelenburg  posture  may  aid  very  materially  in  this.     The  knee-chest  pos- 


Fig.   373.      Showing    the    Method    of    Testing    the    Mobility    of    such    a    Mass.       (Ashton — 

Practice  of   Gynecology.} 

ture,  taken  for  a  few  seconds,  may  cause  the  organs  to  return  to  the  abdominal 
cavity.  Careful  examination  may  show  the  organ  absent  from  its  normal 
position.  If  it  is  the  kidney,  there  may  or  may  not  be  bladder  symptoms  or 
urinary  abnormalities. 


B.  Mass,  Behind  Cervix,  Contains  Fluid 

1.  Pelvic  Abscess  (Fig.  370)  from  salpingitis,  from  oophoritis,  from  cel- 
lulitis, from  hematocele  or  hematoma,  from  a  suppurating  solid  tumor  or  from 
a  suppurating  cyst. 

2.  Intraperitoneal  Hemorrhage  (Fig.  371).  This  usually  comes  from 
lubal  pregnancy,  with  rupture  of  the  wall  of  the  tube  or  abortion  from  the  end 


302  GYNECOLOGIC   DIAGNOSIS 

of  the  tube  into  the  peritoneal  cavity.    Blood  in  the  peritoneal  cavity  presents 
one  of  three  conditions,  as  f  oUoavs  : 

a.  The  blood  may  be  free  in  the  cavity.  This,  like  ascites,  does  not  give 
rise  to  any  distinct  mass  or  induration,  hence  does  not  require  consideration 
here.     The  characteristics  of  this  condition  are  given  in  Chapter  xi. 

b.  Clots  and  fibrinous  exudate  forming  a  mass  about  the  affected  tube 
and  extending  from  the  tube  into  the  cul-de-sac.  This  forms  a  mass.  If  there 
is  a  large  amount  of  plastic  exudate,  the  mass  is  rather  firm  and  with  definite 
outlines.  If  the  mass  is  made  up  principally  of  recent  blood  clots,  it  is  soft 
and  the  outlines  indistinct.  This  condition  is  found  in  those  cases  where  there 
are  repeated  slight  hemorrhages.  This  is  a  dangerous  state  of  affairs  for, 
though  the  bleeding  has  stopped  temporarily,  any  exertion,  or  a  disturbance 
of  the  clots  by  an  examination,  may  start  a  severe  hemorrhage. 

c.  Some  blood  has  run  into  the  cul-de-sac  and  a  firm  roof  of  fibrinous 
exudate  has  formed  above  it,  shutting  it  off  completely  from  the  general 
peritoneal  cavity.  This  condition  is  called  pelvic  ''hematocele,"  and  repre- 
sents the  least  dangerous  condition  of  intraperitoneal  hemorrhage. 

The  physical  signs  of  intraperitoneal  clotted  blood  and  exudate  are  practi- 
cally the  same  as  those  of  inflammatory  exudate,  with  the  exception  of  the 
temperature.  There  is  usually  but  little  fever  after  the  first  forty-eight  hours, 
and  in  many  cases  not  much  at  any  time.  Of  course,  if  suppuration  comes  on 
later  in  the  blood  mass,  then  the  ordinary  signs  of  suppuration  appear,  includ- 
ing fever.  The  diagnosis  of  a  blood  mass,  rather  than  an  inflammatory  mass, 
must  rest  largely  upon  the  absence  of  decided  fever  in  the  presence  of  acute 
symptoms  and  upon  certain  points  in  the  history  and  progress,  indicating  a 
tubal  pregnancy.    These  points  are  given  under  tubal  pregnancy  in  Chapter  xi. 

3.  Hydrosalpinx  low  in  the  cul-de-sac.  The  prolapsed  and  distended 
tube  may  be  movable  or  adherent. 

4.  Parovarian  Cyst  pushing  back  behind  cervix  and  filling  the  posterior 
part  of  the  pelvis. 

5.  Ovarian  Cyst  in  cul-de-sac  (Figs.  372,  373).  A  small  ovarian  cyst  may 
easily  drop  into  the  cul-de-sac.  If  it  becomes  adherent  it  will  remain  there, 
choking  the  pelvis  as  it  enlarges. 

6.  Cystic  Fibroid.  This  presents  the  characteristics  of  a  fibroid,  with 
fluctuation  and  some  tenderness  added. 

7.  Uterus  Containing  Fluid  and  displaced  backward.  The  fluid  in  the 
uterus  may  be  due  to  pregnancy  or  to  a  cystic  fibroid  in  the  wall  or  to  pus 
or  to  blood. 

8.  Small  Cyst  of  Some  Abdominal  Structure  lying  in  cul-de-sac.  Such 
a  cyst  may  come  from  the  omentum,  from  the  mesentery  or  from  a  prolapsed 
kidney  or  spleen. 

9.  Ureter  Greatly  Dilated  (hydro-ureter  or  pyo-ureter)  and  filling  in  back 
of  the  uterus. 


MASS   LOW   AND    IX   FRONT    OP    CERnX 

MASS  LOW  AND  IN  FRONT  OF  CERVIX 


303 


A.  Mass  or  Induration  Firm 

1.  Uterus  Displaced  Forward.     There  may  be  any  of  the  solid  conditions 
of  the  uterus  already  mentioned. 

2.  Fibroid  Tumor  of  Uterus  (Fig.  374). 

3.  Malignant  Disease  of  cervix  extending  forward  or  of  the  urethra  ex- 
tending backward  or  of  the  vagina,  may  give  induration  in  front  of  the  cervix. 

4.  Cellulitis,  between  uterus  and  bladder.     The  characteristics  of  an  in- 
duration from  cellulitis  have  alreadv  been  a-iven. 


Fig.   374.     A    Fibroid    forming    a    Mass    in    front    of    the    uterus.       (Thomas    and    Munde — 

Diseases  of   IVotnen.) 

5.  Bladder  Disease.  This  may  be  a  tumor  (Fig.  375)  or  tuberculosis 
(Fig.  376)  or  chronic  inflammation. 

B.  Mass,  in  Front  of  Cervix,  Contains  Fluid 

1.  Bladder  Distended  with  Urine  (Fig.  324).  "Whenever,  in  making  a 
bimanual  examination,  a  cystic  mass  is  felt  in  front  of  the  uterus,  catheterize 
the  patient  if  necessary  to  eliminate  a  full  bladder. 

2.  Uterus  Containing-  Fluid.  This  is  usually  due  to  pregnancy,  though  it 
may  rarely  be  due  to  pyometra  or  hematometra. 

3.  Pelvic  Abscess.  A  pelvic  abscess  in  this  situation  is  usually  due  to  a 
cellulitis. 

4.  Pelvic  Hematoma.  Occasionally  a  hematoma  from  tubal  pregnancy 
will  dissect  in  between  the  uterus  and  bladder  and  give  a  fluctuating  mass 
in  this  region,  but  this  is  very  rare. 

5.  Vaginal  Cyst.     This  projects  into  the  vagina,  and  the  fluid  appears  to 


304 


GYNECOLOGIC    DIAGNOSIS 


Fig.  375.     A   Tumor  of  the  Bladder.      (Ashton — Practice   of   Gynecology.) 


Fig.   376.     Tuberculosis     of    the    Bladder,     forming    a    Mass    in     front     of    the    uterus. 
(Dudley — Practice    of    Gynecology.) 


MASS    LOW    AND    FILLING    PELVIS 


305 


be  just  beneath  the  vaginal  walh     Its  point  of  attachment  is  very  low,  ap- 
parently in  the  vesico-vaginal  septum. 

6.  Parovarian  Cyst.     Such  a  cyst  may  grow  in  between  the  uterus  and 
the  bladder. 

7.  Cystic  Fibroid.    A  fibroid  groAving  from  the  anterior  part  of  the  cervix 
may  displace  the  l)ladder  upward  and  give  a  mass  just  in  front  of  the  cervix. 


Fig.   377.     Inflammatory    Exudate    filling   the   pelvis   and    forming   a    firm    roof    above    the    examining   fingers 
The    resisting   "roof"    usually    follows    about    the    line    indicated    in    Fig.    378. 


Fig.   378.     Indicating   the   general    direction    of  the   lower   surface    of   the   "roof   of   exudate"   in   most    cases. 
(Thomas    and    Munde — Diseases    of    Women.) 


MASS  LOW  AND  FILLING  PELVIS 

A.  Mass  or  Induration  Firm 

1.  Extensive   Inflammatory   Exudate    or    infiltration,    from    salpingitis, 

oophoritis,  peritonitis  or  cellulitis  (Fig.  377).  This  extensive  inflammatory 
exudate  fixes  all  the  organs,  as  though  plaster  of  Paris  had  been  run  in 
around  them  and  had  hardened  there.     On  making  the  vaginal  examination 


306 


GYNECOLOGIC   DIAGNOSIS 


Fig.   379.     Pelvis  filled  with  a  Bony  Tumor  from  the  pelvic  wall.      (A.   Martin — Atlas  of   Gynecology.) 


Fig.   380.     Pelvis  and   Lower  Abdomen   filled  with  a  Mass  composed   of   a   Pregnant  Uterus  and   an 
Ovarian    Cyst.      (Williams,   after   Bumm — Obstetrics.) 


MASS   HIGH   IN   RIGHT    SIDE  307 

tliere  is  found  a  firm  roof  above  the   examiiiiiig  fingers,   on  approximately 
the  plane  indicated  in  Fig.  378. 

2.  Extensive  Bleeding  in  the  pelvis,  in  the  form  of  hematoma  or  hema- 
tocele or  blood  clots  without  limiting  roof  of  exudate. 

3.  Large  Fibroid  in  lower  part  of  uterus.  This  may  be  any  one  of  the 
various  forms  of  fibromyoma. 

4.  Malignajit  Disease  of  cervix  or  corpus  uteri  or  of  bladder  or  of 
rectum.     There  may  be  malignant  disease  and  fibroid. 

5.  Tumor  from  Pelvic  Wall  (Fig.  379). 

B.  Mass,  Low  and  Filling  Pelvis,  Contains  Fluid 

1.  Uterus  Pregnant.  The  enlarged  and  fluctuating  uterus  may  be  in 
normal  position  or  in  displacement  (Fig.  330).  It  may  be  regular  in  shape  or 
very  irregular   (Figs  344,  345,  346). 

2.  Parovarian  Cyst.  This  may  grow  low  in  the  pelvis  and  fill  it,  displac- 
ing the  organs  in  various  directions. 

3.  Ovarian  Cyst.  An  ovarian  cyst  bound  down  by  adhesions,  may  fill  the 
pelvis  and  extend  to  the  lower  part  of  it.  There  may  be  some  complicating 
condition,  for  example,  an  ovarian  cyst  and  pregnancy  (Fig.  380). 

4.  Pelvic  Abscess  with  extensive  exudate  or  infiltration  may  fill  the 
pelvis.  The  point  of  fiuctuation  is  usually  behind  the  cervix.  Most  of  the 
mass  is  firm,  and  there  is  the  firm  inflammatory  roof  previously  mentioned. 

5.  Collection  of  Blood  in  pelvis.  This  may  be  present  in  the  form  of  hema- 
toma or  hematocele.  In  addition  to  an  area  of  fluctuation,  there  is  usually 
the  firm  roof  due  to  accompanying  infiltration  and  exudate. 

MASS  HIGH,  IN  PELVIS  OR  LOWER  ABDOMEN,  RIGHT  SIDE 

A.  Mass  or  Induration  Firm 

1.  Uterus  Displaced.  Any  one  of  the  various  solid  conditions  of  the 
uterus  previously  mentioned  may  form  a  mass  in  the  center  of  the  pelvis  or  to 
one  side. 

2.  Salpingitis.  There  may  be  simply  a  thickened  tube  (Fig.  381)  or  a 
large  mass  of  exudate. 

3.  Pyosalpuix,  with  small  amount  of  pus  and  such  a  thick  wall  that  no 
fluctuation  is  obtained.  There  may  be  very  little  peritubal  exudate  or  a 
great  deal. 

4.  Oophoritis,  without  any  cyst  large  enough  to  give  fluctuation.  There 
may  be  little  or  no  exudate  or  there  may  be  a  large  amount  of  exudate. 

5.  Adhesions,  from  any  of  the  above  conditions.  The  adhesions  may  be 
slight  or  extensive. 

6.  Cellulitis,  in  upper  part  of  broad  ligament,  or  resulting  scar-tissue  from 
same. 


308 


GYNECOLOGIC   DIAGNOSIS 


7.  Thrombosis  of  Veins  of  Broad  Ligament  (Fig.  382),  This  condition, 
though  rar©,  probably  occurs  more  frequently  than  is  generally  supposed. 

8.  Solid  Tumor  of  Ovary  or  Tube.  This  may  be  small  or  large,  movable 
or  adherent. 

9.  Extrauterine  PregTiancy.  This  may  be  tubal  pregnancy  (Fig.  383)  or 
pregnancy  in  a  rudimentary  horn  of  the  uterus  (Figs.  384,  385).  For  the 
special  evidences  of  extrauterine  pregnancy  see  Chapter  xi.    Tubal  pregnancy, 


Fig.   381.     Salpingitis    Nodosa.       (Thomas    and    Munde — Diseases    of    Women.) 

with  its  resulting  hemorrhage  and  plastic  exudate  and  adhesions  binding  to- 
gether the  various  structures  and  giving  a  tender  mass  in  the  tubo-ovarian 
region,  is  most  frequently  mistaken  for  an  ordinary  inflammatory  m.ass. 

10.  Pelvic  Tuberclosis.    The  mass  presents  the  characteristics  of  a  chronic 
inflammatory  mass,  which  in  fact  it  is.     The  fact  that  the  inflammation  is  tu- 


Fig.   382.     Thrombosis   of    Veins    of   the   broad   ligament.      (Schaeffer — Hand-Atlas   of    Gynecology.) 

bercular  must  be  determined  by  other  features  of  the  case  than  the  pelvic 
palpation.  For  these  other  diagnostic  points,  see  pelvic  tuberculosis  in  Chap- 
ter XI. 

11.  Fibroid  Tumor  of  Uterus.  This  is  subperitoneal  and  may  be  pedicu- 
lated  (Fig.  351)  or  sessile  (Fig.  352). 

12.  Appendicitis  with  Exudate.  The  mass  is  situated  about  the  appendix 
and  the  history  points  to  bowel  trouble,  rather  than  to  tubal  trouble.  In 
some  cases  the  appendix  extends  into  the  tubal  region,  causing  more  or  less 


MASS    HIGH   IN   RIGHT    SIDE 


309 


confusion  in  diagnosis.  The  various  situations  which  the  appendix  has  been 
found  to  occupy  in  different  cases,  without  change  of  the  position  of  the  ce- 
cum, are  shown  in  Fig.  387.  In  cases  where  the  cecum  varies  from  the  usual 
position,  the  appendix  may  be  still  farther  from  its  normal  position,  as  indi- 
cated in  Fig.  386.  In  a  case  of  appendicitis  there  may  be  a  point  of  pain  and 
tenderness  elsewhere  in  the  abdomen,  in  addition  to  that  in  the  appendix 
region.  Then  immediately  arises  the  question,  ''Do  any  of  these  additional 
areas  of  tenderness  represent  an  additional  lesion  or  is  the  pain  and  tender- 
ness simply  reflex  from  the  inflamed  appendix?"  The  author's  friend,  Dr.  Leon- 
idas  Kirby,  of  Harrison,  Arkansas,  recently  called  his  attention  to  the  following 
method  of  identifying  the  reflex  areas  of  tenderness.  With  the  patient's 
knees  drawn  up  to  relax  the  abdominal  muscles  as  in  regular  abdominal  pal- 
pation, note  the  areas  of  tenderness.  Then  make  steady  pressure  exactly 
over  the  appendix  sufficient  to  cause  decided  pain  and,  while  maintaining  this 


Fig.   383.      Tubal    Pregnancy    in    the    Right    side.       (Dickinson — American    Textbook    of    Obstetrics.) 


pressure  over  the  appendix,  palpate  with  the  other  hand  the  areas  which  are 
tender.  When  the  tenderness  in  the  other  areas  is  reflex,  it  disappears  as  long 
as  the  pressure  over  the  appendix  is  maintained,  to  reappear  as  soon  as  the 
pressure  over  the  appendix  ceases.  Dr.  Kirby  has  found  this  simple  expedient 
very  helpful  in  a  considerable  number  of  doubtful  cases. 

13.  Fecal  Mass,  in  cecum  and  extending  along  the  ascending  colon. 

14.  Tumor  of  Cecum.  This  is  usually  malignant.  It  presents  chronic 
irritation  in  the  cecal  region,  generally  leading  to  a  diagnosis  of  chronic  ap- 
pendicitis. 

There  are  exacerbations  of  trouble  at  times,  due  apparently  to  irrita- 
tion in  the  cecum  from  retained  fecal  material.  In  some  cases  there  is  a 
swelling  in  this  region,  that  comes  and  goes.  It  is  most  marked  usually 
during  the  days  of  pain  and  disappears  largely  Avhen  the  bowels  are  well 
opened.     Later  a  permanent  mass  appears,  though  it  may  vary  considerably 


310 


GYNECOLOGIC   DIAGNOSIS 


in  size  at  different  times,  due  to  the  varying  amount  of  fecal  material  in  the 
cecum.  This  same  history  may  be  present  at  times  in  chronic  cecitis  without 
a  tumor,  but  in  such  a  case  of  course  there  is  no  permanent  tumor,  unless 
there  is  some  complicating  inflammatory  trouble  around  the  cecum. 

.  15.  Intussusception.  The  mass  extends  along  the  cecum  and  ascending 
colon.  There  is  the  history  of  intestinal  obstruction,  the  passage  of  bloody 
mucus  from  the  bowel  and  the  rectal  tenesmus.  It  is  most  frequent  in  children. 
16.  Displaced  Kidney  (Fig.  388).  The  mass  has  approximately  the  size 
and  shape  of  the  kidney  and  is  tender  when  pressed  upon.  Pressure  usually 
causes  a  desire  to  urinate,  and  it  may  cause  pain  running  along  the  ureter  to 
the  bladder.  The  prolapsed  kidney  is  usually  somewhat  enlarged.  Unless 
adherent  in  its  malposition,  it  may  be  returned  to  its  bed  in  the  loin.  This 
facility  with  which  the  kidney  slips  up  into  its  bed  when  the  patient  is  lying 
on  her  back,  sometimes  interferes  with  the  diagnosis,  for  palpation  then  would 
show  no  displacement  of  the  kidney.    In  order  to  prevent  a  prolapsed  kidney 


Fig.   384.     Pregnancy    in    the    Rudimentary   Horn    of    a    malformed    uterus. 
Sanndcr's    Year    Book,    1904.) 


(Jay's    Case — 


from  being  pushed  into  place  unawares,  during  palpation  in  the  vicinity,  it  is 
well  to  grasp  the  lumbar  region  firmly,  as  shown  in  Fig.  389.  This  fixes  the 
kidney  in  its  abnormal  position,  where  it  can  be  palpated  by  the  fingers  of  the 
other  hand,  as  shown  in  Fig.  390.  Another  way  to  examine  a  movable  kidney 
in  its  lowest  position,  is  to  palpate  the  loiii  while  the  patient  is  standing.  The 
patient  must  lean  forward  on  some  support  in  such  a  way  as  to  relax  the  ab- 
dominal muscles. 

17.  Tumor  of  Kidney.  Such  a  mass  may  be  traced  up  into  the  kidney 
region.  If  the  tumor  and  kidney  are  prolapsed,  they  may  be  returned  to  the 
loin,  if  not  adherent.  There  are  usually  dragging  pains  in  the  loin,  and  blad- 
der symptoms.  Urinary  examination  may  give  decisive  information.  A  very 
satisfactory  method  of  palpating  the  kidney  region  for  a  mass,  or  for  deep 
tenderness,  is  to  use  both  hands,  one  behind  and  the  other  in  front,  the  lum- 
bar structures  being  caught  between  them. 

18.  Perinephritic  Abscess,  Avithout  distinct  fluctuation.     This  may  dissect 


MASS    HIGH   IN   EIGHT    SIDE  311 

down  into  the  lower  abdomen,  and  even  into  the  pelvis,  and  still  be  so  deeply 
situated  as  not  to  give  definite  fluctuation,  except  under  anesthesia.  The 
mass  may  be  traced  uj3  into  the  kidney  region.  There  is  colon  resonance  over 
it.  There  is  marked  tenderness  in  the  lumbar  region,  and  usually  decided 
swelling  there.  There  is  the  history  and  the  ordinary  signs  of  kidney  dis- 
turbance, associated  with  the  general  and  local  evidences  of  suppuration. 

19.  Psoas  Abscess,  without  distinct  fluctuation.  This  causes  a  deep  seated 
mass  in  the  lower  abdomen,  which  may  give  no  fluctuation  until  it  approaches 
the  surface  in  the  neighborhood  of  Poupart's  ligament.  As  it  is  usually  tuber- 
cular, the  marked  local  tenderness  and  the  high  fever  and  chills  of  ordinary 
deep  suppuration  are  generally  absent.     A  careful  examination,  however,  will 


Fig.   385.     Pregnancy    in    a    Rudimentary    Horn    of    the  Uterus.      As    there    is    no    communicating 

cavity    between    the    uterine    cavity    and    site    of    the    pregnancy  in    the    rudimentary    horn,    the    spermatozoa 

evidently  came  by  way  of  the  opposite  tube,  as  indicated  by  the  small  arrows.  (Kelly — Operative 
Gynecology.) 

show  more  or  less  fixation  of  the  thigh.  When  an  attempt  is  made  to  move 
the  thigh  in  any  direction  that  pulls  the  psoas  muscle,  the  movement  is  re- 
sisted.   There  are  also  other  evidences  of  caries  of  the  lumbar  vertebrae. 

20.  Enlarged  Liver  or  Solid  Tumor  of  Liver.  The  liver  occasionally  be- 
comes so  enlarged  from  disease  or  abscess  formation  that  its  lower  border  is 
pushed  into  the  right  lower  abdomen.  The  direct  connection  of  the  mass 
with  the  usual  liver  dullness  may  be  demonstrated,  and  the  lower  border  and 
left  border  of  the  mass  has  the  shape  of  the  liver  and  there  is  a  history  indi- 
cating liver  disease.  A  tumor  from  the  liver  usually  lies  in  front  of  the  in- 
testines and  its  connection  with  the  liver  may  be  directly  sho^^nii  by  palpation 
and  percussion.     Also,  there  is  a  history  of  liver  disturbance. 


312 


GYNECOLOGIC    DIAGNOSIS 


21.  Movable  Liver.  Exceptionally  the  liver  may  be  so  movable,  that  it 
sinks  into  the  lower  abdomen.  The  mass  lies  in  front  of  the  intestines,  has 
the  shape  of  the  liver  and  may  be  returned  into  the  liver  region  unless  ad- 
herent. 

22.  Tumor  of  Abdominal  Wall  (Fig.  131).  This  is  a  rare  condition,  and 
for  that  reason  it  is  likely  to  be  forgotten,  resulting  in  a  mistaken  diagnosis. 
The  distinguishing  signs  of  a  tumor  of  the  abdominal  wall  are  given  in  the 
first  part  of  this  chapter. 


hind    cecum. 


mesial    fo  cecum  over  ueurrL. 
II        n        .1       under       » 


behind  tUo-cecdt^ 
Junctioa 


in  iliac   fossa 


along    iliac  vessels 


Fig.   386.     Diagram    showing    various    positions    in    which    the    Appendix    vermiformis    may    lie,    with    the 
cecum  in  the   usual   place.      (Kelly — Diseases  of  the  Appendix.) 


23.  Inflammatory  Mass  in  Abdominal  Wall.  This  presents  about  the  same 
signs  as  a  tumor  of  the  wall,  with  evidences  of  inflammation  added. 

24.  Tumor  of  Round  Ligament.  It  arises  somewhere  in  the  course  of  the 
round  ligament,  either  in  the  pelvic  cavity  or  in  the  inguinal  canal.  If  large, 
it  necessarily  produces  great  distortion  of  the  parts.  It  may  cause  much 
confusion  in  diagnosis  if  the  fact  be  not  remembered  that  a  tumor  occasionally 
arises  from  this  ligament. 

25.  Some  Central  Abdominal  Mass.    One  of  the  firm  masses  mentioned  as 


MASS   HIGH   IN   EIGHT    SIDE 


313 


usually  appearing  in  the  central  abdomen,  may  be  displaced  to  one  side  or 
may  become  so  large  that  it  extends  far  over  to  both  sides. 

26.  Mass  from  Opposite  Side.  Occasionally  an  enlarged  organ  or  a  tumor 
from  one  side,  will  become  so  much  displaced  as  to  appear  to  belong  to  the 
other  side. 

B.  Mass,  High  in  Right  Side,  Contains  Fluid 

1.  Uterus  Displaced.  The  fluctuation  may  be  due  to  pregnancy  or,  very 
rarely,  to  pyometra  or  to  hematometra. 


Fig.   387.     Diagram    showing    various    positions    which     the    Cecum    and    Appendix    may    occupy,     in    cases 
where  the  cecum  is  displaced.     Kelly — Diseases  of  the  Appendix.) 

2.  Pyosalpinx  (Figs.  391,  392,  393).  There  is  a  tender  mass  in  the  tubo- 
ovarian  region,  with  slight  or  well-marked  fluctuation.  The  mass  is  fixed  and 
the  uterus  also  is  fixed.  There  may  be  a  large  amount  of  firm  exudate  or  very 
little.  There  is  usually  a  clear  history  of  infection  followed  by  the  usual  evi- 
dences of  pelvic  inflammation,  including  persistent  endometritis  with  dis- 
charge. If  the  trouble  is  gonorrheal,  the  symptoms  may  be  mild,  and  if  of 
long  standing  the  pus-tube  may  not  be  very  tender.  But  there  is  more  tender- 
ness and  more  thickening  and  fixation  than  occurs  with  hydrosalpinx  or 
ovarian  cyst  or  parovarian  cyst. 

3.  Ovarian  Abscess.  This  presents  practically  the  same  history  and  the 
same  signs  as  a  tubal  abscess.  In  fact,  it  is  sometimes  impossible  to  say 
with  absolute  certainty  whether  the  pus  is  in  an  enlarged  tube  or  an  en- 
larged ovary.  As  the  former  is  the  usual  condition,  we  assume  in  a  given 
case,  that  the  pus  is  in  the  tube,  unless  there  is  something  special  pointing 


514 


GYNECOLOGIC   DIAGNOSIS 


otherwise.  Occasionally  in  an  abscess  in  this  region,  the  form  can  be  made 
out  as  distinctly  round  (probably  ovary)  or  distinctly  long  and  sausage-shaped 
(tubal). 

4.  Tubal  Pregnancy.  This  presents  the  history  and  examination  signs 
of  an  inflammatory  mass,  with  the  history  and  progress  of  tubal  pregnancy. 
There  is,  in  the  class  of  cases  now  under  consideration,  sufficient  fluid  blood 
encapsulated  somewhere  to  give  fluctuation,  either  about  the  tube  or  in  the 
posterior  cul-de-sac. 


Fig.  388.  Movable  Kidney,  showing  the  outline  of  the  displaced  kidney  as  determined  by  palpa- 
tion. Notice  that  the  kidney  comes  well  below  a  line  drawn  from  the  umbilicus  to  the  right  anterior 
superior  iliac  spine    (marked   by  a  cross). 

5.  Pelvic  Tuberculosis.  There  are  the  signs  of  a  chronic  inflammatory 
mass,  with  a  collection  of  fluid  (tubercular  pus),  and  the  history  and  progress 
of  the  case  present  the  characteristics  of  local  tuberculosis,  as  explained  in 
Chapter  xi. 

6.  Hydrosalpinx  (Fig.  394).  About  the  same  as  ovarian  cyst  except  that 
it  is  oblong  and  extends  from  the  uterus  to  the  pelvic  wall  and  is  attached 
along  the  border  of  the  broad  ligament.  The  signs  are  much  like  those  due  to 
parovarian  cyst,  except  that  the  hydrosalpinx  is  situated  high  while  still 
small.     There  may  or  may  not  be  a  history  of  pelvic  inflammation  at  any 


MASS    HIGH    IN    RIGHT    SIDE 


315 


time.    Its  intimate  attachment  to  the  uterine  horn  is  an  important  diagnostic 
point. 

7.  Ovarian  or  Parovarian   Cyst    (Figs.   395,   396).     A  fluctuating  mass, 
somewhat  moval)le,  of  sIoav  growth,  with  no  acute  symptoms  if  not  compli- 


Fig.  389.  Palpation  of  a  Movable  Kidney,  with  a  patient  on  her  back.  First  Step.  The  loin 
is  grasped  as  here  shown,  to  prevent  the  displaced  kidney .  from  slipping  unnoticed  back  into  its  place 
at  the   beginning  of  palpation. 


Fig.   390.     Palpation   of   a   Movable   Kidney,    with   patient    on    her   back.      Second   Step.      Palpating 
the    kidney   with    the    right    hand,    while    it    is    held    in    displacement    with    the    left    hand. 


316 


GYNECOLOGIC    DIAGNOSIS 


cated,  unless  caught  in  the  pelvis,  and  there  is  considerable  abdominal  en- 
largement before  very  troublesome  symptoms  appear.  The  mass  is  attached 
in  the  pelvis  and,  by  further  examination,  its  attachment  may  be  traced  to  the 
tubo-ovarian  region. 


Fig.   391.     Double    Pyosalpinx   with   adhesions.      (Montgomery — Practical   Gynecology.) 


Fig.   392.     Pyosalpinx    with    no     adhesions.       (Kelly — Operative     Gynecology.) 

8.  Cystic  Fibroid.  The  greater  portion  of  the  mass  is  usually  solid  and 
presents  the  characteristics  of  a  uterine  fibroid. 

9.  Large  Perityphlitic  Abscess.  Presents  the  history  of  appendicitis  with 
persistent  septic  symptoms,  and  the  evidences  of  a  pus  collection  in  the 
vicinity  of  the  cecum. 


MASS    HIGH   IN    RIGHT    SIDE 


317 


10.  Cystic  Tumor  of  Kidney.  The  tumor  may  be  traced  up  toward  the 
loin.  It  is  freely  movable  usually,  unless  there  has  been  inflammation  about 
it.  Good  fluctuation  is  not  obtained  through  a  moderately  thick  abdominal 
■wall,  unless  there  is  some  large  cavity  or  a  number  of  small  ones  with  very 
thin  walls-.  The  tumor  may  be  made  up  of  innumerable  small  cysts  and  yet, 
in  the  ordinary  examination,  appear  as  a  solid  tumor.  Under  anesthesia  the 
fluctuation  may  usually  be  distinctly  made  out.  Tenderness  is  slight  unless 
there  is  complicating  inflammation.  The  enlarged  kidney  is  usually  displaced 
doAvnward  considerably,  so  that  there  is  room  in  the  loin  up  into  which  it 
may  be  pushed.  The  colon  lies  over  the  mass,  between  it  and  the  abdominal 
wall.  This  may  not  be  apparent  at  first,  the  colon  being  flattened  out  against 
the  wall  and  causing  no  resonance  on  percussion.     The  fact  that  the  colon 


Fig.   393.      Pyosalpinx    with    very    extensive    adhesions.       (Kelly — Operative    Gynecology.') 

is  over  the  mass  is  easily  demonstrated  by  inflating  the  rectum  and  colon 
with  air.  This  was  necessary  in  the  case  of  the  tumor  shown  in  Fig.  190  (see 
also  Figs.  188  and  189). 

11.  Hydronephrosis  and  Hydro-ureter.  Occasionally  the  kidney  and 
ureter  on  one  side  Avill  become  very  much  dilated,  forming  a  sac  filled  with 
fluid  (urine).  There  is  usually  a  history  of  kidney  pains  and  bladder  disturb- 
ance extending  over  a  long  period  and  varying  much  at  different  times.  The 
characteristic  feature  is  that  the  sac  fills  at  times,  producing  a  sw^elling  with 
more  or  less  tension  and  pain,  and  then  after  a  variable  time  there  is  a  dis- 
charge of  a  very  large  quantity  of  urine  with  disappearance  of  the  swelling 
and  relief  of  the  symptoms.  After  a  time  the  sac  fills  again  and  discharges. 
A  crucial  point  in  the  diagnosis  of  such  a  condition  is  the  coincidence  of  the 
disappearance  of  the  swelling  and  the  discharge  of  an  extraordinarily  large 


318 


GYNECOLOGIC  DIAGNOSIS 


quantity  of  urine.  Too  mucli  dependence  should  not  be  placed  on  the  his- 
tory, as  it  is  more  or  less  uncertain  and  may  lead  to  an  erroneous  conclusion. 
Before  the  patient  is  subjected  to  operation,  in  cases  where  the  symptoms  are 
not  urgent,  she  should  be  required  to  make  daily  measurements  of  the  amount 
of  the  urine  passed  during  one  of  the  periods  of  appearance  and  disappear- 
ance of  the  swelling,  in  order  that  any  marked  increase  in  the  amount  of 
urine,  as  the  swelling  disappears  or  diminishes,  may  be  known  positively. 


R.T. 


R.L. 


R.O. 


L.O. 


R.L. 


Fig.  394.     Right    Hydrosalpinx.  U,    Uterus    split    open.      R.T.    Right    Tube,    distended    with    fluid    (hydro- 
salpinx).    R.L.  Round  ligaments.     R.O.  Right  ovary.      (Keating  and  Coe — Clinical  Gynecology.) 


Fig 


395.     Ovarian    Cyst    of    Right    side,    displacing    uterus    to    the    left. 
Practical    Gynecology.) 


(Montgomery- 


12.  Pyonephrosis.  When  the  dilated  kidney  or  ureter  becomes  filled  with 
pus,  there  is  marked  disturbance,  with  fever,  chills,  pains  extending  from 
kidney  to  bladder,  usually  marked  bladder  disturbance  and  definite  urinary 
findings.     Palpation  of  the  kidney  and  along  the  course  of  the  ureter  gives 


MASS    HIGH   IN   RIGHT    SIDE 


319 


marked  tenderness.  An  important  feature  in  tliese  eases  of  painful  kidney 
trouble  is  the  point-tenderness  on  deep  pressure  in  the  lumbar  just  over  the 
kidney.  (Fig.  162).  This  helps  to  differentiate  kidney-tenderness  from  tender- 
ness due  to  appendiceal  or  other  intraperitoneal  inflammation,  which  differ- 
entiation may  in  some  cases  be  practically  impossible  by  palpation  in  front. 
Usually,  however,  careful  palpation  in  front  will  show  clearly  that  the  tender- 
ness is  in  the  kidney  and  along  the  course  of  the  ureter. 

13.  Perinephritic  Abscess,  large  enough  to  give  fluctuation.  This  may 
burrow  into  the  pelvis  or  towards  Poupart's  ligament.  It  gives  deep  fluctua- 
tion and  presents  the  symptoms  and  signs  of  deep  suppuration  in  the  kidney 
region. 

14.  Psoas  Abscess,  large  enough  to  give  fluctuation.  This  may  burrow 
into  the  pelvis,  or  beneath  Poupart's  ligament  to  the  femoral  opening.     It 


Fig.  396.     Graafian-Follicle    Cysts    of   the   ovaries,    which   have   become    intraligamentary. 

Operative  Gynecology.) 


(Kelly- 


presents  fluctuation,  both  superficial  and  deep,  and  gives  the  symptoms  and 
signs  of  tuberculosis  of  the  lumbar  vertebrae  with  involvement  of  the  psoas 
muscle. 

15.  Dilated  Gall-bladder.  Occasionally  the  gall-bladder  becomes  so  greatly 
enlarged  and  displaced,  that  it  extends  into  the  lower  abdomen.  The  con- 
nection of  the  fluctuating  mass  with  the  liver  may  be  traced,  and  there  is  a 
history  of  gall-stone  disease  or  other  liver  disturbance. 

16.  Central  Abdominal  Affection.  One  of  the  cystic  masses  mentioned  as 
usually  appearing  principally  in  the  median  line,  may  be  displaced  to  one 
side  or  may  become  so  large  that  it  extends  far  over  to  both  sides. 


320  GYNECOLOGIC    DIAGNOSIS 

17.  Mass  from  Opposite  Side.  Occasionally  a  cystic  mass  from  one  side 
will  become  so  much  displaced  that  it  appears  to  belong  to  the  opposite  side. 
In  a  ease  operated  recently,  there  was  an  ovarian  cyst  extending  to  the  um- 
bilicus. The  history  indicated  that  it  had  been  unusually  movable,  occupying 
various  positions,  in  the  lower  abdomen.  When  seen,  the  patient  had  been  sick 
in  bed  several  days  with  abdominal  pains  and  evidences  of  a  mild  peritonitis. 
The  large  fluctuating  mass  occupied  the  left  and  central  portions  of  the  lower 
abdomen  and  pelvis.  The  small  uterus  was  crowded  into  the  posterior  part 
of  the  pelvis  behind  the  cyst.  The  cystic  mass  was  not  very  tender,  but  it  was 
fixed  immovably  by  adhesions.  From  its  location  there  seemed  no  room  for 
doubt  that  it  arose  from  the  left  side.  On  opening  the  abdomen,  however,  it 
was  found  that  it  was  a  right  ovarian  cyst  which  had  fallen  over  to  the  left 
side  in  front  of  the  uterus.  The  pedicle  had  become  twisted,  with  resulting 
hemorrhage  into  the  cyst  and  fibrinous  peritonitis  about  it.  To  the  torsion  of 
the  pedicle,  with  the  resulting  hemorrhage  and  peritonitis,  Avere  due  the  acute 
symptoms  and  the  recent  fixation  of  the  cyst. 

MASS  HIGH,  IN  PELVIS  OR  LOWER  ABDOMEN,  LEFT   SIDE 

A.  Mass  or  Induration  Firm 

Same  as  on  right  side,  substituting  Sigmoid  flexure  for  Cecum,  and 
Spleen  for  Liver,  and  leaving  out  Appendicitis. 

B.  Mass  Contains  Fluid 

Same  as  on  right  side,  substituting  Cyst  of  Spleen  for  dilated  Gail-Blad- 
der, and  leaving  out  Perityphlitic  Abscess. 

MASS  HIGH  AND  IN  MEDIAN  LINE 

In  Pelvis  or  Lower  Abdomen  or  Central  Abdomen 

A.  Mass  or  Induration  Firm 

Any  of  the  solid  masses  mentioned  as  occurring  in  the  Right  or  Left 
side,  may  extend  to  the  Median  line  or  across  it. 

There  are,  however,  certain  flrm  masses  that  arise  in  or  near  the  median 
line  and,  consequently,  may  be  classed  as  belonging  to  this  median  region. 

1.  Solid  Tumor  of  Uterus.  Fibroid  tumors  are  the  most  frequent  cause  of 
firm  enlargement  of  the  uterus,  though  occasionally  a  malignant  tumor  of  the 
corpus  uteri  will  cause  marked  enlargement.  The  characteristics  of  these 
have  already  been  given.  There  may  exceptionally  be  both  carcinoma  and 
fibroid   (Fig.  397). 


MASS    HIGH    AND   IN    MEDIAN   LINE 


321 


2.  Abdominal  Pregnancy  and  Lithopedion  (Figs.  398,  399,  400). 

3.  Solid  Tumors  of  Omentum,  Small  Intestine  or  Mesentery.     These  usu- 
ally appear  near  the  median  line,  and  the  signs  vary  with  the  location.     The 


Fis 


397.      Large   Mass   in    Pelvis   formed   by   Uterine   Fibroids    and    Carcinoma.      (Cullen- 
Cancer   of   the    Uterus.) 


diagnosis  rests  upon  the  presence  of  a  mass  presenting  the  symptoms  and  signs 
to  be  expected  in  a  tumor  from  one  of  these  structures,  and  for  which  no 
more  common  disease  would  account.  Such  tumors  usually  are  accompanied 
by  gastro-intestinal  symptoms. 

4.  Tumor  of  Pancreas.  A  deep-seated  mass  in  the  median  line,  accom- 
panied by  decided  evidences  of  pancreatic  disturbance,  and  presenting  syiiap- 
toms  and  signs  for  which  nothing  else  w^ill  account.  * 


322 


GYNECOLOGIC   DIAGNOSIS 


Fig.  400.  Showing  the  Lithopedion  re- 
moved, and  also  the  site  of  the  Tubal 
pregnancy.  (Kelly — Operative  Gynecol- 
ogy.) 


Fig.   399.      Extrauterine    Pregnancy    with    I,ithopedion.      Showing 
the  Lithopedion   in  situ.      (Kelly — Operative  Gynecology.') 


MASS   HIGH   AND   IN    MEDIAN   LINE 


323 


5.  Retroperitoneal  Tumor  (Fig.  187).  It  lies  back  of  the  intestines,  is 
rather  movable,  more  so  than  would  be  expected  from  a  pancreatic  tumor, 
and  is  without  evidences  of  disturbance  of  any  particular  organ, 

6.  Enlarg-ed  Lymphatic   Glands.     This  condition  presents  the  evidences 


Fig.  401.     The    Kidney    Displaced    into    the    Pelvis.      (Dudley — Practice    of    Gynecology.) 


Fig.   402.     A   Earge    Cystic    Fibroid.      (Montgomery — Practical    Gynecology.) 


324 


GYNECOLOGIC  DIAGNOSIS 


of  a  retroperitoneal  or  mesenteric  mass,  accompanied  with  a  disease  causing 
glandular  enlargement,  such  as  Hodgkin's  disease,  or  with  recent  ulceration 
in  the  intestine   (tubercular  or  typhoid). 

7.  Tubercular  Peritonitis,  Avithout  enough  fluid  to  give  fluctuation.  Tuber- 
cular inflammation,  with  the  exudate  and  resulting  mass,  may  occur  at  any 
part  of  the  peritoneal  cavity,  but  is  likely  to  extend  into  the  median  line, 
if  not  there  primarily.     The  patient  presents  the  evidences  of  a  chronic  or 


Fig.   403.      Ovarian    Cyst    with    a    long    slender    pedicle.       (Montgomery — Practical    Gynecology.) 


subacute  peritonitis  with  nothing  else  to  account  for  it,  and  the  presence  of 
tuberculosis  in  the  intestines  or  in  the  lungs. 

8.  Displaced  Abdominal  Organ.  Several  cases  are  recorded  in  which  a 
displaced  organ,  such  as  the  kidney  (Fig.  401)  or  the  spleen,  has  led  to  an  er- 
roneous diagnosis  and  an  erroneous  operation. 


MASS    HIGH   AND   IN    MEDIAN   LINE 


325 


B.  Mass,  High  and  in  Center,  Contains  Fluid 

Any  of  the  fluid  masses  mentioned  as  occurring  in  the  Right  or  Left 
side,  may  extend  to  the  median  line  or  beyond  it. 

There  are,  however,  certain  fluctuating  masses  that  arise  in  the  median 
line  and  hence  may  be  said  to  belong  to  this  region. 

1.  Pregnant  Uterus.  This  may  be  any  size,  may  be  normal  or  abnormal, 
and  the  shape  of  the  uterus  may  be  regular  or  irregular. 

2.  Cystic  Fibroid  (Fig.  402.)  It  presents  the  evidences  of  a  fibroid  along 
with  fluctuation  in  a  part  of  it.  Where  such  a  condition  is  found,  be  careful 
to  exclude  pregnancy  complicating  the  fibroid. 


Fig.   404.     Dermoid    Cyst    filling    front    of    pelvis    and    displacing    the    uterus    backward. 
(Montgomery — Practical  Gynecology.) 


3.  Distended  Bladder  (Fig.  147).  This  may  cause  much  confusion  in 
examination  and  diagnosis.  The  diagnostic  points  have  already  been  given. 
It  has  happened  that  the  unrecognized  distended  bladder  ruptured  with  fatal 
results   (Fig.  148). 

4.  Ovarian  or  Parovarian  Cyst  (Figs.  403,  404).  The  diagnostic  points 
have  been  given  briefly  in  this  chapter,  and  are  given  in  detail  in  Chapter  xii. 

5.  Ascites.  For  the  differential  diagnosis  of  ascites,  see  text  and  illus- 
trations under  Percussion  in  this  chapter. 

6.  Ascites  and  Tumor  (Fig.  405).  The  important  percussion  signs  of 
ascites  and  tumor  have  already  been  mentioned  and  illustrated  in  this  chapter 
(see  Figs.  180,  181,  182). 

7.  A  Cystic  Tumor  of  Omentum,  Intestine  or  Mesentery.    A  considerable 


326 


GYNECOLOGIC   DIAGNOSIS 


number  of  cystic  tumors  of  the  omentum  and  mesentery  have  been  reported. 
Such  tumors  may  cause  much  confusion  in  diagnosis,  unless  it  be  kept  in  mind 
that  they  may  be  encountered.  The  symptoms  and  signs  they  present  depend 
on  the  situation,  and  may  be  worked  out  for  the  different  situations  by  a 
consideration  of  the  surrounding  structures  and  the  signs  that  would  likely 
result.  The  diagnosis  depends  largely  on  the  exclusion  of  the  more  common 
conditions. 


Fig.  405.  Ascites  and  Fibroid.  Tiie  combination  closely  simulated  pregnancy.  The  abdomen  was 
distended  with  a  Fluid  Mass  having  a  Solid  Mass  inside,  and  the  peculiarly  shaped  fibroid  gave  ballotte- 
ment.      (Montgomery — Practical    Gynecology.) 


8.  Pseudocyst  of  the  Lesser  Omental  Cavity.  This  is  usually  preceded 
some  months  by  an  al)dominal  injury  involving  the  pancreas.  It  is  likely  to 
be  of  rather  slow  growth,  and  the  injury  may  be  overlooked  unless  the  his- 
tory is  carefully  inquired  into.  In  all  cystic  masses  of  doubtful  character  near 
the  center  of  the  abdomen,  this  should  be  thought  of. 

9.  Cyst  of  Pancreas.    A  true  cyst  of  the  pancreas  may  present  much  the 


DIFFERENTIAL   DIAGNOSIS    OF   VARIOUS    MASSES 


327 


same  symptoms  and  signs  as  the  pseudocyst  of  the  lesser  omental  cavity  re- 
sulting from  an  injury  of  the  pancreas.  Space  can  not  be  taken  to  give  in 
detail  the  differential  diagnosis  of  these  various  upper  abdominal  conditions. 
The  author  wishes  simply  to  call  attention  to  the  conditions  that  may  be 
encountered,  and  the  presence  or  absence  of  which  must  be  determined  by 
the  examiner  through  further  study. 

10.  Cyst  of  Urachus.  This  and  other  rare  abnormalities  are  occasionally 
met  with.  A  cyst  of  the  urachus  is  found  in  or  near  the  median  line,  and  be- 
tween the  peritoneum  and  the  anterior  abdominal  wall.  It  may  communicate 
with  the  umbilicus,  causing  an  intermittent  discharge  there,  or  with  the  blad- 
der or  with  neither. 

POINTS  IN  DIFFERENTIAL  DIAGNOSIS 

OF  VARIOUS  MASSES  IN  THE  PELVIS  OR  LOWER  ABDOMEN 

The  majority  of  mistakes  in  diagnosis  are  due  not  so  much  to  want 
of  knowledge  as  to  lack  of  application  of  the  knowledge  possessed.  A  diag- 
nosis in  a  difficult  case  implies  (first)  a  careful  examination,  by  which  are  ob- 
tained the  essential  facts  of  the  case,  and  (second)  correct  reasoning  and  a 
logical  conclusion,  based  on  those  facts.  A  mistake  in  diagnosis  may  be  due 
to  failure  to  get  all  the  essential  facts — some  important  points  being  over- 
looked. In  order  to  prevent  this  in  the  class  of  cases  under  consideration 
(presenting  a  mass  in  the  pelvis  or  lower  abdomen),  the  author  gives  the 
following  table  of  points  to  be  considered.  In  a  difficult  case,  consult  this 
table  and  notice  whether  or  not  you  have  obtained  the  information  avail- 
able on  the  various  points  mentioned. 


Examination  Findings 

1.  Position  of  mass. 

2.  Size. 

3.  Shape. 

4.  Consistency. 

5.  Tenderness. 

6.  Mobility. 

7.  Attachments. 

8.  Apparent  point  of  origin. 

9.  Relation  to  uterus. 

10.  Position  of  uterus. 

11.  Size  of  uterus. 

12.  Shape  of  uterus. 

13.  Consistency  of  uterus. 


14.  Tenderness  of  uterus. 

15.  Mobility  of  uterus. 

16.  Discharge  from  uterus. 

17.  Discoloration  of  cervix  or  vagina. 

18.  Eelation    of   mass      to    tube    and 

ovary. 
Relation  of  mass  to  pelvic  wall. 
Relation  of  mass  to  vaginal  wall. 

Bladder  (full,  distended,  urinary 
incontinence,  induration  in 
bladder,  pain  on  pressure). 

Rectum  (containing  fecal  masses, 
or  indurated  or  painful  on  pres- 
sure). 


19 

20 
21 


22 


528 


GYNECOLOGIC    DIAGNOSIS 


23.  Mass     elsewhere      (arising     from 

uterus  or  about  tube  or  along 
colon). 

24.  Colon  or  small  intestine  between 

mass  and  abdomen  wall. 

25.  Outline  of  dullness. 

26.  Shifting  of  outline  of  dullness. 

27.  Hard  masses  within  a  cystic  mass. 

28.  Pulsation  of  mass,  felt  on  exam- 

ination. 

29.  Fetal   movements,   felt    on   exam- 

ination. 
80.  Vascular  murmur  heard. 

31.  Fetal  heart  sounds  heard. 

32.  Fever  present. 

33.  Emaciation,  or  fat  deposition. 

34.  Breast  disturbance  (tenderness, 

enlargement,  enlarged  veins 
with  milk  formation). 

35.  Evidence     of     disease     of    heart, 

lungs,  liver,  kidneys,  gastro-in- 
testinal  tract,  spleen,  pancreas, 
nervous  system. 

History  and  Subjective  Symptoms 

36.  Manner  of  onset,  prominent  symp- 

toms and  apparent  cause. 

37.  General  course  since. 

38.  Menstrual  disturbance. 

39.  Intermenstrual  bloody  discharge. 

40.  Leucorrhea. 

41.  Pain  in  lower  abdomen  or  pelvis 

(pressure,  aching,  sharp  pain) 
or  about  external  genitals,  or 
backache  (sacral,  lumbar,  loin) 
or  thigh  pains. 

42.  Fever. 

43.  Disability. 

44.  Variation  in  weight. 

45.  Abdominal   enlargement. 

46.  Morning    sickness,    or    persistent 

nausea  or  vomiting  at  other 
times. 


47.  Breast     disturbance — pains,     ten- 

derness, enlargement,  pigmen- 
tation, enlarged  veins,  milk 
formation. 

48.  Bladder  or  rectal  disturbance,  pre- 

ceding or  accompanying  the 
trouble. 

49.  Evidence  of  disease  of  the  heart, 

lungs,  liver,  kidneys,  gastro- 
intestinal tract,  spleen,  pan- 
creas, nervous  system. 

Progress  Under  Observation 

50.  Steady    increase    or    decrease,    or 

exacerbations,  etc. 

If  Examination   Under  Anesthesia 
Notice : 

51.  Exact  position  of  mass. 

52.  Exact  size  and  shape. 

53.  Consistency  throughout. 

54.  Exact  mobility. 

55.  All  the  attachments. 

56.  Point  of  origin. 

57.  Exact  relation  to  adjacent  organs, 

to  uterus, 

to  Fallopian  tubes, 

to  ovaries, 

to  rectum, 

to  colon. 

58.  Uterus — exact  position,  size,  shape, 

consistency,  (tenderness  not  ap- 
preciable) ,  mobility,  attach- 
ments. 

59.  It  may  be  advantageous  to  make 

recto-abdominal  examination 
also. 

60.  If  cervix  is  suspicious  of  malig- 

nant disease,  excise  a  piece  for 
microscopic  examination. 


POINTS   IN    SPECULUM    EXAMINATION 


329 


If  Necessary  for  Diagnosis,  and  Per- 
missible Under  the  Conditions 
Present,  Explore  the  Uterine 
Cavity : 

61.  With  sound,   to   determine   depth 
and  direction. 


62.  With  curet,  to    secure    tissue    for 

microscopic  examination. 

63.  With  finger,  to  determine  consist- 

ency of  uterine  wall  (softened 
area,  hard  nodule)  and  pres- 
ence of  retained  placental  rem- 
nants or  projecting  polypoid 
growths. 


POINTS  IN  THE  SPECULUM  EXAMINATION 

In  the  speculum  examination,  direct  inspection  is  made  of  the  vaginal  wall 
and  the  cervix. 


Fig.   406.     Primary   Malignant   Ulceration   of   the   Vagina.      (Montgomery — Practical   Gynecology.) 


Conditions  of  Vaginal  Wall 

The   vaginal  wall  may   present   arterial   congestion,   venous   congestion, 
bleeding  areas  or  distinct  ulceration. 

Arterial  Congestion  of  the  Vaginal  Wall  indicates  inflammation,  usually 


330 


GYXECOLOGIC    DIAGNOSIS 


acute,  or  active  irritation,  as  by  an  irritating  discharge  or  pessary  or  other 
foreign  body.  The  differential  diagnosis  of  the  various  forms  of  vaginal  in- 
flammation has  already  been  given  in  this  chapter,  when  considering  leucor- 
rhea.  Occasionally  there  are  cases  of  chronic  vaginitis  in  which  there  is 
arterial  congestion  in  spots.  In  such  chronic  cases  there  is  likely  to  be  infil- 
tration and  hypertrophy  of  the  congested  areas,  giving  rise  to  the  condition 
known  as  granular  vaginitis. 

Venous  Congestion  of  the  Vaginal  Wall  should  always  arouse  a  suspicion 
of  pregnancy,  for  that  is  the  most  common  cause.    It  may  be  caused,  also,  by 


Fig.  407.  Secondary  Malignant  Ulceration  of  the  \'agina.  In  this  case  there  was  a  carcinoma 
of  the  endometrium,  and  the  discharge  caused  an  implantation  carcinoma  where  the  cervix  came  in 
constant    contact    with    the    posterior    vaginal    wall.       (Kelly — Operative    Gynecology.) 

a  tumor  or  other  pelvic  mass  that  interferes  with  the  vaginal  circulation,  or 
by  extrapelvic  conditions  that  cause  venous  stasis  in  the  pelvis,  such  as  heart 
disease  with  failing  compensation. 

Bleeding  Areas  on  Vaginal  Wall,  without  a  distinct  ulcer,  are  found 
principally  in  senile  or  adhesive  vaginitis,  which  is  described  in  Chapter  iv. 

A  Distinct  Ulcer  on  the  Vaginal  Wall  may  be  simple,  chancroidal,  syph- 
ilitic, tubercular  or  malignant.  In  the  case  of  a_  malignant  ulcer,  it  may  be 
primary  on  the  vaginal  wall  (Fig.  406)  or  it  may  be  secondary  (Fig.  407),  the 


POINTS   IN   SPECULUM    EXAIMINATION 


331 


Fig.  408. 


Fig.   409. 


Fig.  410. 


Figs.  408  and  409.     Varieties   of  Normal   Cervix  in   the  Virgin.      Fig.   410.      Cervix   of  Multipara. 
(Norris,   after   Heitzmann — American    Textbook    of   Obstetrics.) 


Fig.   411.     A  Senile   Cervix,  with  upper  part  of 
vagina.      (Edgar — Practice    of   Obstetrics.) 


Fig.  412.  Discharge  from  the  Cervix-  Uteri,  as 
seen  through  the  speculum.  (Massey — Conservative 
Gynecology.) 


Fig.  413.     Discharge,  with  Laceration  and  Erosion  of 
the  Cervix.      (Massey — Conservative   Gynecology.) 


Fig.  414.  Erosion  of  the  Cervix,  with 
a  few  scattered  cysts.  (H.  MacNaughton- 
Jones — Diseases  of   Women.) 


332 


GTXECOLOGIC    DIAGNOSIS 


{iicVTiul  rji-  er'osioii  oi'cf^rxnx. 


Der-ij   sif'ilato    Incorali 


with   erosion    of  one  lip. 


u)  to  irnior  os  . 


Fig.  415.     Lacerations    and    Erosions    of    the    Cervix.       (Mann — American    System    of    Gynecology.) 


POINTS   IN   SPECULUM    EXAMINATION 


333 


ruihil.-ial    laci-i-L-lioi; 
ho\'0!'.(!  vn':;;itai   instM-h'iii 


l)oul)l(>  i.)iii-a!i.jn 


Doul.l. 
bt>VOTlf!    \ 


(    nilii  ijU'  I 


Fig.  415.     Lacerations    and    Erosions   of   the    Cervix.      (Mann — American   System   of    Gynecology.) 


SM 


GYNECOLOGIC  DIAGNOSIS 


most  common  source  of  secondary  malignant  ulceration  of  the  vaginal  wall 
being  carcinoma  of  the  cervix  uteri. 

Conditions  of  Cervix  Uteri 

The  appearance  of  the  normal  virgin  cervix  is  shown  in  Figs.  408  and  409. 
The  appearance  of  the  approximately  normal  cervix  in  the  parous  woman  is 
shown  in  Fig.  410,  and  a  cervix  that  has  undergone  the  senile  atrophy  is  shown 


Fig.  417. 


418. 


Figs.  417  and  418.  Testing  for  the  extent  of  the  tear,  in  cases  where  the  cervix  has  the  appear- 
ance of  a  ball.  The  center  of  the  anterior  lip  (A.  Fig.  417),  and  of  the  posterior  lip  (B)  are  each 
caught  with  a  tenaculum  and  brought  together,  as  indicated  in  Fig.  418.  (Baldy- — American  Textbook 
of  Gynecology.) 


Fig.   419.     Beginning   Epithelioma   of  the   Cervix. 
(Sampson — Johns   Hopkins  Hospital  Bulletin.) 


Fig.  420.  Beginning  Carcinoma  of  the  Interior 
of  the  Cervix.  (Sampson — Johns  Hopkins  Hospital 
Bulletin.) 


in  Fig.  411.  Fig.  412  shows  discharge  from  an  unlacerated  cervix,  while  Fig. 
413  shows  discharge  and  laceration.  Erosion  of  the  cervix  is  a  very  common 
condition,  being  present  to  a  greater  or  less  extent  in  most  cases  where  there 
is  an  irritating  discharge.  Fig.  414  shows  erosion  of  the  cervix,  the  shaded 
area  extending  out  from  the  external  os  representing  the  red  angry-looking 
erosion.  A  few  small  glandular  cysts  are  also  visible.  Various  appearances 
of  lacerated  cervix,  as  seen  through  the  speculum,  are  shown  in  Figs.  415, 


POINTS   m   SPECULUM    EXAMINATION 


335 


•'ig.   421.      Kpithelioma  of  the   Cervix.      The   cervix   has   been   destroyed,   leaving   only   an   area    of   cancerous 
ulceration    at    the    top    of   the   vagina.      (Kelly — Operative    Gynecology.) 


m 


GYNECOLOGIC   DIAGNOSIS 


416.  Ill  a  considerable  proportion  of  cases,  distinct  lips  are  not  at  first  appar- 
ent, the  lacerated  cervix  having  the  appearance  of  a  ball  (Fig.  417).  In  such 
a  case,  if  the  anterior  and  posterior  portions  of  the  cervix  be  caught  with  a 
forceps  or  tenaculum  and  brought  together,  as  indicated  in  Fig.  418,  the  ex- 
tent of  the  laceration  becomes  apparent. 


Fig.  422.  Epithelioma  of  the  Cervix.  The  cervix  has  been  destroyed  and  the  affected  area  has 
been  drawn  in,  by  the  gradual  contraction  of  the  infiltrated  tissues,  until  no  cancerous  tissue  can  be 
seen.  Palpation,  however,  shows  that  there  is  infiltration  of  the  area  enclosed  within  the  dotted  line. 
(Kelly — Operative    Gynecology.) 


Malignant  disease  of  the  cervix  causes  many  thousands  of  deaths  annually 
and  yet  in  the  beginning  it  is  entirely  local  and,  when  recognized  early,  can  be 
completely  removed.  The  diagnosis  is  considered  in  detail  in  Chapter  ix.  Here 
the  author  wishes  simply  to  call  attention  to  the  fact  that  beginning  malignant 
disease  may  make  very  little  change  in  the  general  appearance  of  the  cervix. 


PAIN    IN   PELVIS    OR    LOWER    ABDOMEN 


337 


Any  suspicious  area  should  be  carefully  investigated  and,  if  necessary  to  a  posi- 
tive diagnosis,  a  small  piece  should  be  excised  for  microscopic  examination. 
Beginning  malignant  disease  of  the  cervix  is  shown  in  Figs.  419,  420,  421. 
Fig.  422  shows  the  cervix  destroyed  and  drawn  in  by  contracting  tissue,  so  that 


Fig.   423.      Epithelioma    of   the    Cervix,    appearing   as    a    Papillary    Growth.      {KeWy —Operative    Gynecology.) 

no  ulceration  is  visible  through  the  speculum.  But  in  the  vaginal  palpation  in 
this  case  distinct  induration  was  felt  in  the  area  bounded  by  the  dotted  line. 
Fig.  423  shows  a  case  where  the  carcinoma  has  appeared  in  the  form  of  a  papil- 
lary growth. 

PAIN  IN  PELVIS  OR  LOWER  ABDOMEN 

Pain  in  the  pelvis  or  loAver  abdomen  may  be  due  to: 

1.  Salpingitis,  Acute  or  Chronic.  Pain  referred  to  tubo-ovarian  region 
(Fig.  155).  History  of  preceding  uterine  inflammation,  with  cause  for  same. 
If  chronic,  history  of  preceding  exacerbations.  On  abdominal  palpation,  ten- 
derness in  tubo-ovarian  region.  On  vaginal  and  bimanual  examination,  there 
is  found  vaginal  discharge  (evidence  of  preceding  uterine  inflammation)  and 
marked  tenderness  in  tubal  region.  Mass  is  indurated,  extending  up  to  uterine 
horn  and  out  to  pelvic  wall.  Fixation  of  upper  part  of  uterus  and  pain  on 
movement   of  uterus.     Absence   of   special   signs   of  tubal   pregnancy   or   of 


338  GYNECOLOGIC    DIAGNOSIS 

chronic  oophoritis.  Mass  may  be  solid  (consisting  only  of  exudate  or  infiltra- 
tion) or  may  give  more  or  less  fluctuation,  due  to  serous  fluid  (hydrosalpinx) 
or  to  pus  (pyosalpinx).  AH  these  conditions  are  included  under  the  term 
salpingitis. 

2.  Oophoritis,  Acute  or  Chronic.  Acute  or  subacute  inflammation  of  the 
ovary  ordinarily  j)resents  practically  the  same  diagnostic  points  as  salpingitis, 
is  usually  associated  with,  and  overshadowed  by,  the  salpingitis  and  is  in- 
cluded under  the  general  term  "pelvic  inflammation."  There  is,  however,  one 
rather  common  form  of  oophoritis  not  associated  with  salpingitis,  namely, 
the  cystic  or  cirrhotic  form.  When  not  associated  with  salpingitis  or  peri- 
toneal exudate,  there  is  felt  on  bimanual  examination,  a  tender  mass  in  the 
tubo-ovarian  region — rounded,  about  the  size  of  the  ovary  or  larger,  softened, 
with  occasionally  a  fluctuating  area,  movable,  often  lying  lower  than  the  ovary 
usually  does  (prolapse  of  ovary  behind  uterus)  and  when  pressed  upon  pro- 
duces a  peculiar  sickening  pain.  There  is  absence  of  peritoneal  exudate  and 
there  is  no  fi^xation. 

3.  Pelvic  Cellulitis.  Signs  same  as  in  salpingitis  except  induration  very 
hard  (unless  collection  of  pus)  and  occupying  connective  tissue  areas,  situ- 
ated lower  at  side  of  uterus  and  intimately  connected  with  uterus  or  pelvic 
wall. 

4.  Endometritis,  Acute  or  Chronic.  Pelvic  pain  slight,  sense  of  weight  and 
pressure  in  the  pelvis.  Uterine  discharge,  excessive  menstruation,  tenderness 
of  uterus,  no  induration  or  marked  tenderness  outside  uterus. 

5.  Backward  Displacement  of  Uterus.  If  uncomplicated,  the  pelvic  pain 
is  slight  but  there  is  a  sense  of  pressure  and  weight.  Body  of  uterus  absent  in 
front  of  cervix.  Back  of  cervix  can  be  felt  a  mass  which,  on  further  investi- 
gation, proves  to  be  the  body  of  the  uterus. 

6.  Fibroid  Tumor  of  Uterus.  Unless  tumor  is  very  large  and  chokes  pelvis, 
pelvic  pain  is  slight  but  there  is  a  sense  of  weight  and  pressure.  Frequently 
uterine  discharge  and  excessive  menstruation.  No  history  of  uterine  infec- 
tion or  attacks  of  pelvic  inflammation.  Firm  mass  firmly  attached  to  uterus, 
not  tender,  not  movable  separately  from  uterus,  but  uterus  and  mass  mov- 
able together  in  pelvis  (i.e.,  no  fixation  of  uterus  and  mass  to  pelvic  wall)  ex- 
cept when  tumor  is  so  large  as  to  fill  pelvis.  In  deep  seated  fibroids,  mass  may 
appear  as  an  enlarged  uterus. 

7.  Cancer  of  Uterus.  Leucorrhea,  with  occasionally  a  streak  of  blood. 
No  pain  at  first  but  later,  when  uterus  is  much  enlarged  (cancer  of  corpus)  or 
infiltration  involves  parametrium  (cancer  of  cervix),  pain  appears.  If  in  the 
cervix,  there  is  indurated  area  or  an  ulcer  that  resists  treatment,  and  a  piece 
should  be  excised  for  microscopic  examination.  If  from  the  body  of  uterus, 
there  is  a  leucorrheal  discharge  or  a  blood-streaked  discharge  that  resists 
treatment,  the  interior  of  the  uterus  should  be  curetted  and  the  scrapings 
examined  microscopically.     In  the  later  stages  there  is  a  bleeding  mass,  with 


PAIN    IN   PELVIS   OR   LOWER   ABDOMEN  339 

indurated  margins,  at  site  of  cervix,  or  a  bloody,  watery  fonl-sraelling  dis- 
charge from  the  interior  of  the  uterus.  A  bloody  foul-smelling  watery 
discharge  does  not  necessarily  mean  cancer.  It  may  be  due  to  a  fibroid,  the  dif- 
ferential diagnosis  being  made  by  microscopic  examination  of  clippings  or 
curettings,  when  necessary. 

8.  Painful  Menstruation  (Dysmenorrhea).  Pain  due  to  menstruation 
alone,  occurs  only  at  the  menstrual  periods,  though  pain  from  most  any  pelvic 
disease  may  be  much  increased  at  the  menstrual  period,  on  account  of  the 
menstrual  congestion  and  increased  nerve  sensitiveness.  The  various  causes 
of  dysmenorrhea  and  the  differential  diagnosis,  are  given  in  Chapter  xiv. 

9.  Pregnancy,  with  Threatened  Miscarriage.  Pains  are  usually  some- 
what paroxysmal,  missed  menses,  morning  sickness,  pains  in  breasts,  begin- 
ning softening  of  cervix,  uterine  body  enlarged  and  softened,  elasticity  of 
middle  segment  (Hegar's  sign),  bluish  coloration  of  vaginal  walls  and  cervix. 

10.  Incomplete  Miscarriage.  History  of  early  pregnancy,  pain  and  pass- 
ing of  blood  clots  or  "pieces  of  flesh,"  foUoAved  by  a  bloody  discharge  ana 
occasional  pains.  The  pains  are  usually  slight  (unless  infection  has  taken 
place),  the  principal  symptom  being  the  persistent  bloody  discharge.  Cervix 
and  body  of  uterus  softened.  Cervix  open,  and  sometimes  pieces  of  membrane 
and  of  blood  clot  may  be  felt  projecting  out  of  it. 

11.  Tubal  Pregnancy.  Missed  menses,  morning  sickness,  uterus  slightly 
enlarged  and  softened,  tender  mass  in  tubal  region.  Diagnosis  on  these  signs 
not  justifiable,  unless  previous  examination  of  pelvis  has  shown  it  free  from 
tubal  or  ovarian  inflammatory  trouble.  If  rupture  takes  place,  pain  and  ten- 
derness are  so  marked  and  so  severe  at  first  as  to  preclude  satisfactory  palpa- 
tion of  tubo-ovarian  regions.  If  hemorrhage  is  severe,  pulse  is  affected.  If 
slight,  pain  disappears  and  mass  can  be  made  out  beside  uterus  or  behind  it. 
The  signs  at  this  stage  (slight  peritoneal  hemorrhages  and  resulting  peritoneal 
irritation  and  exudate)  are  the  same  as  for  acute  salpingitis  with  exudate, 
with  the  following  special  features : 

a.  Bloody  vaginal  discharge,  beginning  within  a  few  days  after  onset  of 
pain  and  continuing  in  an  irregular  way  from  one  to  several  weeks. 

b.  Only  slight  fever  or  none.  With  enough  acute  inflammation  to  cause 
such  severe  symptoms,  there  should  be  considerable  and  persistent  fever. 

c.  Evidence  of  internal  hemorrhage,  to  a  greater  or  less  extent. 

d.  Exacerbations  of  pain  without  apparent  cause  and  without  decided 
elevation  of  temperature. 

e.  Absence  of  recent  intrauterine  pregnancy  (miscarriage  and  infection 
are  very  common  causes  of  ordinary  salpingitis). 

12.  Pelvic  Tuberculosis.  Evidences  of  pelvic  inflammation  (tenderness, 
induration  or  mass  beside  or  behind  the  uterus  or  filling  pelvis,  fixation  of 


340  GYNECOLOGIC   DIAGNOSIS 

Uterus,  fever  and  exacerbations),  with  the  special  features  given  for  pelvic  tu- 
berculosis in  Chapter  xi. 

13.  Tumor  of  Ovary,  Broad  Ligament  or  Fallopian  Tube.  A  mass  (usually 
soft,  fluctuating)  in  tubo-ovarian  region,  not  tender,  usually  freely  movable. 
Not  intimately  attached  to  uterus,  no  fixation  of  uterus  unless  mass  is  large 
enough  to  displace  uterus  to  side  of  pelvis.  Ovarian  growths  are  usually 
freely  movable  and  tend  to  rise  out  of  the  pelvis,  while  broad  ligament  growths 
are  held  firmly  within  the  broad  ligament  and  cause  pain  and  uterine  dis- 
placement while  still  small. 

14.  Laceration  of  the  Pelvic  Floor.  Loss  of  support  in  pelvic  floor  causes 
more  or  less  dragging  and  pressure  in  pelvis  (though  rarely  severe  pain),  pres- 
ent principally  when  patient  is  on  her  feet,  much  relieved  when  she  lies  down. 
Feeling  of  weakness  at  pelvic  outlet,  and  may  be  protrusion  of  parts  (colpo- 
cele,  cystocele,  rectocele,  prolapse  of  uterus).  Examination  shows  marked  loss 
of  support  in  pelvic  floor. 

15.  Acute  Vaginitis.  Pelvic  pain  slight  and  very  low  (more  of  pressure 
and  weight  and  burning),  free  discharge,  vulvar  and  urethral  irritation.  Ex- 
amination shoAvs  purulent  discharge  and  evidences  of  acute  inflammation  of 
vagina. 

There  are  a  number  of  extragenital  diseases  that  may  cause  pain  in  the 
pelvis  and  lower  abdomen  and  that  may  be  confounded  with  gynecologic  af- 
fections, and  that  consequently  must  be  taken  into  consideration  in  differential 
diagnosis.     Among  them  may  be  mentioned  the  following : 

16.  Appendicitis.  Pain  more  diffused  through  abdomen  and  about  um- 
bilicus at  beginning  of  attack.  Tenderness  at  McBurney's  point,  and  no 
particular  tenderness  over  tube.  Mass  in  appendix  region,  and  not  in  tubo- 
ovarian  region.  Attacks  associated  with  gastro-intestinal  symptoms  rather 
than  with  uterine  symptoms,  though  pain  may  be  worse  at  menstrual  periods 
on  account  of  menstrual  congestion.  Mass  may  involve  both  regions — if  in 
virgin  probably  appendicitis,  if  in  married  woman  probably  salpingitis. 

17.  Mucous  Colitis.  Causes  severe  attacks  of  pain  in  lower  abdomen  and 
pelvis,  and  has  frequently  been  mistaken  for  uterine  or  tubal  or  ovarian  dis- 
ease. Patients  have  been  given  pelvic  treatment  for  months  and  years  and 
have  even  had  the  ovaries  removed  when  the  trouble  Avas  none  other  than  this 
peculiar  affection  of  the  colon.  The  affection  is  known  by  various  names,  such 
as  membranous  enteritis,  tubular  diarrhea  and  mucous  colic. 

Osier  states:  "It  is  a  remarkable  disease,  to  which  attention  has  been 
paid  for  several  centuries.  It  is  an  affection  of  the  large  bowel  characterized 
by  the  production  of  a  very  tenacious,  adherent  mucous,  which  may  be  passed 
in  long  strings  or  as  a  continuous  tubular  membrane.  I  have  twice  had  op- 
portunity of  seeing  the  membrane  in  situ,  closely  adherent  to  the  mucosa  of 
the  colon,  but  capable  of  separation  without  any  lesion  of  the  surface.  Ac- 
cording to  AV.  A.  Edwards,  80  per  cent  of  the  recorded  adult  cases  have  been 


N   IN   PELVIS   OR    LOWER   ABDOMEN  341 


ill  Avomeii.  The  cases  are  almost  invariably  seen  in  nervous  or  hysterical 
women  or  in  men  with  neurasthenia.  All  grades  of  the  affection  occur,  from 
the  passage  of  a  slimy  mucous  like  frog-spawn  to  large  tubular  casts  a  foot 
or  more  in  length.  Microscopically  the  casts  are,  as  shown  by  Sir  Andrew 
Clark,  not  fibrinous  but  mucoid  and  even  the  firmest  consist  of  dense,  opaque, 
transformed  mucous.  It  is  due  to  a  derangement  of  the  mucous  glands  of  the 
colon,  the  nature  of  which  is  quite  unknown.  The  disease  persists  for  years, 
varying  extremely  from  time  to  time,  and  is  characterized  by  paroxysms  of 
pain  in  the  abdomen,  tenderness,  occasionally  tenesmus,  and  the  passage  of 
flakes  or  long  strings  of  mucous,  sometimes  of  definite  casts  of  the  boAvel.  The 
attacks  last  for  a  day  or  in  some  cases  for  ten  days  or  two  weeks.  Mental 
emotions  or  worry  of  any  sort  seem  particularly  apt  to  bring  on  an  attack. 
Occasionally  errors  in  diet  or  dyspepsia  precedes  an  outbreak.  Membrane  is 
not  passed  Avitli  every  paroxysm,  even  when  pains  and  cramps  are"  severe. 
There  are  instances  in  which  the  morphia  habit  has  been  contracted  on  ac- 
count of  the  pain.  There  may  be  marked  nervous  symptoms,  and  authors  men- 
tion hysterical  outbreaks,  hypochondriasis  and  melancholia.  The  diagnosis  is 
rarely  doubtful  (when  this  affection  is  in  mind)  but  it  is  important  not  to 
mistake  other  substances  for  membranes,  thus  the  external  cuticle  of  asparagus 
and  undigested  portions  of  meat  and  sausage  skins,  sometimes  assume  forms 
not  unlike  mucous  casts,  but  microscopic  examination  will  quickly  differ- 
entiate them." 

This  affection  may  prove  confusing  when  associated  with  endometritis 
or  other  pelvic  lesion.  The  points  in  the  differentiation  of  mucous  colitis  from 
a  serious  painful  pelvic  disease,  are  the  character  of  the  pain  (resembling  in- 
testinal cramps  and  extending  throughout  the  lower  abdomen),  the  passage  of 
characteristic  masses  of  mucous  in  some  of  the  attacks  and  the  absence  of 
any  palpable  pelvic  lesion  to  account  for  the  symptoms. 

18.  Other  Intestinal  Affections — digestive  disturbance,  enteritis,  colitis, 
dysentery,  typhoid  fever,  chronic  constipation  (with  distention  and  toxemia), 
intestinal  tuberculosis.  Each  of  these  may  cause  pain  in  the  lower  abdomen 
and,  if  there  happens  to  be  accompanying  uterine  symptoms,  may  lead  to  a 
mistaken  diagnosis.  Pain  is  more  widespread  and  variable.  Tenderness  on 
palpation  is  more  general  and  ill-defined,  all  the  lower  abdomen  being  more 
or  less  tender  and  the  tenderness  may  extend  above  the  umbilicus  and  into  the 
flanks.  Uterine  and  tubo-ovarian  region  not  especially  tender.  No  palpable 
lesion  in  pelvis  to  account  for  symptoms.  Special  gastro-intestinal  symptoms 
elicited  on  questioning. 

19.  Peritoneal  Tuberculosis.  This  very  closely  resembles  ordinary  chronic 
pelvic  inflammation  in  its  symptoms  and  course.  The  differential  diagnostic 
points  are  given  in  Chapter  xi. 

20.  Kidney  or  Ureteral  Affections — movable  kidney,  nephrolithiasis,  pyone- 
phrosis, ureteritis,  and  tuberculosis  of  kidney  or  ureter.    Each  of  these  affec- 


342  GYNECOLOGIC   DIAGNOSIS 

tions  causes  attacks  of  pain,  involving  the  lower  abdomen  and  pelvis.  Pain 
begins  in  kidney  region  and  extends  downward  along  ureter  to  bladder. 
There  may  or  may  not  be  accompanying  bladder  disturbances  (frequent  or  pain- 
ful urination,  vesical  tenesmus).  On  examination,  tenderness  in  kidney  region 
is  elicited  by  accurate  palpation  of  kidney  and  along  ureter,  and  there  may 
be  displacement  or  enlargement  of  kidney.  On  bimanual  examination,  there 
is  tenderness  in  bladder  or  along  ureter  and  no  palpable  lesion  of  genital  or- 
gans sufficient  to  account  for  symptoms.  There  are  pathologic  findings  in 
the  urine. 

21.  Bladder  or  Urethral  Inflammation  or  Tumor.  History  of  bladder 
symptoms  (frequent  or  painful  urination,  vesical  tenesmus,  urinary  changes). 
On  examination,  tenderness  is  confined  to  urethra,  bladder  or  ureters,  there 
are  pathologic  findings  in  urine  and  no  palpable  lesion  of  genital  organs 
sufficient  to  account  for  the  symptoms.  If  the  case  is  still  doubtful,  instru- 
mental examination  of  urethra,  bladder  or  ureters  may  give  decisive  informa- 
tion. 

22.  Rectal  and  Anal  Diseases — proctitis,  hemorrhoids,  fissure,  new  growths. 
History  of  rectal  symptoms  (pain  on  defecation,  discharge  of  mucus  and  per- 
haps blood  at  times,  protrusion  of  hemorrhoidal  mass).  On  examination,  ten- 
derness and  other  abnormalities  are  found  about  anus  and  extending  up  along 
course  of  rectum.  No  palpable  lesion  in  genital  organs  to  account  for  symp- 
toms. 

23.  Nervous  Diseases — transverse  myelitis,  neurasthenia,  hysteria,  pelvic 
neuralgia.  The  history  indicates  disturbance  of  the  nervous  system,  there  are 
the  special  features  of  one  of  these  nervous  affections  and  there  is  no  palpable 
lesion  of  genital  organs  sufficient  to  account  for  the  symptoms.  Pelvic  tender- 
ness is  confined  to  the  pelvic  nerve  strands  or  to  the  otherwise  apparently  nor- 
mal ovaries.  For  thorough  pelvic  examination  it  may  be  necessary,  in  order 
to  overcome  muscular  tension,  to  examine  under  anesthesia. 

24.  Coccygodynia  (painful  coccyx).  The  painful  affections  of  this  bone, 
either  following  injury  or  of  spontaneous  origin,  are  often  mistaken  for  some 
genital  or  rectal  affection.  The  pain  is  described  by  the  patient  as  at  the  very 
end  of  the  spine,  and  may  radiate  from  there  into  the  pelvis  or  down  the  thigh. 
It  is  noticed  especially  in  positions  that  occasion  movement  of  the  bone  (the 
act  of  sitting  or  rising,  or  straining  at  stool,  or  walking  up  or  down  stairs)  or 
that  cause  pressure  on  the  bone  (resting  on  hard  surface,  riding  on  rough 
road).  On  examination  with  the  finger  in  the  rectum  and  the  thumb  outside 
on  the  bone  (Fig.  85),  there  is  marked  tenderness  on  palpation  of  the  bone 
and  pain  on  movement  of  same.  There  may  be  deformity,  indicating  previous 
injury  or  inflammation.  The  marked  tenderness  is  limited  to  the  region  of 
the  coccyx.  There  is  no  palpable  lesion  of  the  genital  organs  to  account  for 
the  symptoms. 


REFLECTED   PAINS 


343 


BACKACHE 

Backache,  either  in  the  limibar  region  or  extending  down  over  the  sacrum, 
may  be  caused  by  most  any  of  the  conditions  mentioned  under  ''pain  in  the 
pelvis  and  loAver  abdomen."    It  is  not  necessary  to  repeat  them  here. 

In  addition,  backache  may  be  caused  by  affections  of  the  muscles,  nerves, 
ligaments  or  joints  of  this  region,  or  by  affections  of  the  bones  or  spinal  cord. 


Xntffriia. 
Enclnnirtritls 
Bladder > 


Di^phrapaa 


Ovary 


Fig.  424.     Showing   the    usual    cause    of    Reflex    Pains    in    the    various    regions.      (Dana — Textbook    of 

Nervous  Diseases.) 


REFLECTED  PAINS 

Reflected  pains  do  not  occupy  as  large  a  place  in  gynecologic  symptoma- 
tology as  formerly.  We  have  come  to  look  upon  these  distant  pains  in  gyneco- 
logic cases  usually  as  an  indication  of  some  intercurrent  or  complicating 
trouble  at  the  site  of  the  pain  or  of  an  abnormal  condition  of  the  nervous  sys- 


344  GYNECOLOGIC    DIAGNOSIS 

tern,  rather  than  as  a  direct  reflex  from  the  pelvic  trouble.  Careful  investiga- 
tion will  show  this  to  be  the  case  in  the  great  majority  of  instances  of  so-called 
reflex  pains. 

In  rare  cases,  hoAvever,  the  connection  between  the  distant  pain  and  the 
pelvic  lesion  seems  very  close,  as  where,  for  example,  a  pain  in  the  head  or 
other  situation  is  made  to  disappear  by  correction  of  a  retrodisplacement  of 
the  uterus,  only  to  reappear  as  soon  as  the  uterus  returns  to  its  malposition. 

When  reflected  pains  do  occur  they  are  likely  to  be  found  as  indicated  in 
Fig.  424. 

DISTURBANCES  OF  FUNCTION 

The  various  disturbances  of  function  (amenorrhea,  menorrhagia,  irregu- 
lar menstruation,  dysmenorrhea,  dyspareunia,  sterility)  constitute  important 
symptoms  of  disease  in  certain  cases.  They  are  considered  in  detail  in  Chap- 
ters XIV,  and  xv,  where  the  various  causes,  and  consequently  the  diagnostic  sig- 
nificance, of  each  are  given.  Those  disturbances  of  function  due  to  derange- 
ments of  the  ductless  glands  are  considered  in  Chapter  xv. 


CHAPTER  III 

GYNECOLOGIC  TREATMENT 

In  gynecologic  treatment  the  folloAving  therapeutic  measures   are   em- 
ployed : 

Rest. 

Complete  Rest,  in  bed. 
Partial  Rest,  from  work. 
Sexual  Rest. 

Applications  to  Lower  Abdomen  and  Exterior  of  Pelvis. 

Moist  Heat. 
Hot-  Stupes. 
Hot  Pastes. 
Hot  Poultices. 
Hot  Sitz-baths. 
Hot  Moist  Pelvic  Pack. 

Dry  Heat, 

Hot  Water  Bag. 
Japanese  Stove. 
Hot  Water  Coil. 
Electrotherm. 
Hot  Air  Chamber. 
Hot  Dry  Pack. 

Cold  Applications. 
Ice  Bag. 
I  Cold  Coil. 

Cold  Sitz-bath. 

COUNTERIRRITANT  APPLICATIONS. 

Mustard   (poultice,  plaster). 
Cantharides   (plaster,  collodion). 
Tinct.     Iodine. 

Applications  to  External  Genitals,  Vagina  and  Cervix. 

Douches. 
Concentrated  Solutions. 

345 


346  GYNECOLOGIC    TREATMENT 

Powders. 
Tablets. 
'  Vaginal  Suppositories. 
Tampons. 
Tampon-capsules. 
Pessaries. 

Submucous  Injection  of  Substances. 
Local  Blood-letting. 
Curet. 
Cautery. 
Electricity. 
X-Ray. 

Finsen  Light. 
Radium. 

Intrauterine  Treatment. 

Medicated  Applications  within  uterus. 

Hot  Water  L^rigation. 

Curetment. 

Cauterization. 

Electricity. 

Cervical  Dilatation. 

Vacuum  Treatment. 

Applications  Within  Rectum. 

Enemata,  Low  and  High. 
Hot  Water  Irrigation. 

Applications  to  Lower  Abdomen  and  Interior  of  Pelvis. 

Pelvic  Massage. 
Pressure  Treatment. 
Electricity. 

Applications  to  Body  Generally. 

Bathing. 

Friction  Rubbing  (with  alcohol,  salt,  brush,  etc. 

General  Massage. 

Dress  Corrections. 

Postural  Methods  and  Exercise. 

Knee-Chest  Posture. 
Trendelenburg  Posture. 


REST  347 

General  Exercise. 
Special  Exercise. 

Internal  Treatment. 

Medicines. 

Diet. 

Psycho-therapy. 

Operations. 

REST 

Complete  Rest  in  bed  is  necessary  Avhen  acute  inflammation  is  present 
and  in  acute  exacerbations  of  chronic  inflammation. 

In  an  acute  attack  of  vaginitis,  endometritis,  salpingitis  or  acute  pelvic 
peritonitis,  the  patient  should  be  put  to  bed  and  kept  there  until  the  pain  and 
fever  subside.  When  the  inflammation  is  severe  and  accompanied  by  much 
pain,  the  patient  should  use  the  bed-pan  and  should  not  be  permitted  to  get 
up  to  a  vessel  beside  the  bed.  Also,  rest  in  bed  for  a  few  days  will  temporarily 
diminish  the  pain  of  chronic  inflammation  and  the  backache  and  distress  that 
accompany  loss  of  support  in  the  pelvic  floor. 

It  is  a  rule,  with  but  few  exceptions,  that  in  pelvic  disease  strict  rest 
in  bed,  combined  with  laxatives  and  hot  vaginal  douches  and  hot  applications 
to  lower  abdomen,  will  in  twenty-four  to  forty-eight  hours  relieve  the  pain  to 
such  an  extent  that  the  patient  is  comfortable. 

The  exceptions  to  this  rule  are : 

Active  spreading  inflammation  of  the  peritoneum. 

A  collection  of  pus  with  tension. 

Recurrent  hemorrhage,  as  in  tubal  pregnancy. 

Threatened  abortion. 

A  tumor  compressing  pelvic  nerves. 

Neuritis  and  neuralgia. 

In  these  conditions  the  pain  may  be.  persistent  and  severe  in  spite  of 
absolute  rest.  By  keeping  these  things  in  mind,  the  effect  of  rest  becomes 
a  help  in  differential  diagnosis  in  certain  cases. 

Partial  Rest  is  advisable  in  many  cases  that  do  not  require  complete  rest 
in  bed.  The  work  of  some  patients,  requiring  as  it  does  much  Avalking  or 
long  standing  or  constant  running  of  the  serving  machine  or  lifting  of  chil- 
dren, tends  to  aggravate  and  prolong  certain  pelvic  affections  and  for  that 
reason  it  may  be  necessary  to  have  the  patient  stop  work  for  a  while,  even 
though  she  can  ill  afford  financially  to  do  so.  Again,  it  may  be  advisable  to 
direct  a  vacation  to  some  distant  point  for  the  patient  who  is  dragged  down 
by  household  duties  or  the  care  of  children  or  office  work  or  the  exactions  of 


348  GYNECOLOGIC    TREATMENT 

society.  The  rest  from  care,  the  change  of  environment,  the  direction  of  the 
thoughts  and  activities  into  new  channels,  will  in  some  eases  do  more  than 
anything  else  toAvard  restoring  the  patient  to  health.  Directions  should  of 
course  be  given  for  whatever  additional  therapeutic  measures  are  neces- 
sary during  the  visit. 

Sexual  Rest  is  necessary  in  many  cases,  particularly  in  inflammatory 
troubles.  In  some  cases  coitus  must  be  absolutely  forbidden  and  in  other 
cases  restricted,  as  the  marked  congestion  accompanying  it  is  likely  to  ag- 
gravate the  trouble. 

In  acute  inflammation  it  is  rarely  necessary  to  say  anything  on  this  point, 
as  the  painfulness  of  coitus  itself  prevents  it.  In  subacute  inflammations 
however  and  in  chronic  conditions  aggravated  by  pelvic  congestion,  when 
the  trouble  resists  treatment  and  it  seems  probable  that  coitus  is  interfering 
with  the  cure,  it  is  advisable  to  stop  sexual  intercourse  or  restrict  it.  This 
may  be  accomplished  by  one  of  three  ways,  as  follows: 

a.  Instructing  the  patient  or  her  husband  regarding  it.  This  is  some- 
what embarrassing  and  not  very  effective,  though  it  is  sometimes  the  best 
plan. 

b.  Use  of  vaginal  tampons,  the  tampons  to  be  worn  continuously  and 
changed  only  in  the  office.  In  this  way  the  beneficial  effect  of  tampons  is 
secured  and  at  the  same  time  coitus  is  restricted.  The  tampon-capsules  when 
indicated  for  other  purposes,  may  be  used  so  as  to  accomplish  this  object 
also — the  patient  being  directed,  on  removing  each  tampon,  to  take  a  douche 
and  immediately  introduce  the  next  one. 

c.  Sending  patient  on  a  trip  away  from  home.  Here  also  the  sexual 
rest  is  only  incidental,  though  quite  important  in  conditions  aggravated  by 
pelvic  congestion. 

APPLICATIONS  TO  THE  LOWER  ABDOMEN  AND  EXTERIOR  OF 

PELVIS 

These  applications  are  used  to  relieve  pain  and  limit  inflammation. 

MOIST  HEAT 

Hot  stupes  are  made  by  folding  a  piece  of  flannel  several  times,  making 
a  pad  large  enough  to  cover  the  lower  abdomen.  This  pad  is  wrung  out  of 
very  hot  water  and  quickly  applied  to  the  abdomen  and  covered  with  a  piece 
of  thin  oilcloth  or  a  heavy  towel.  The  thin  oilcloth  is  preferable,  as  it 
keeps  in  the  heat  and  moisture  better  and  is  not  so  heavy.  As  soon  as  the 
pad  begins  to  cool,  another  one  is  wrung  from  the  hot  water  and  slipped  in 
place  as  the  first  is  removed.  If  the  stupes  are  changed  frequently  and  thus 
kept  hot,  they  are  very  effective  in  relieving  pelvic  pain. 

They  have  some  effect  in  all  painful  conditions,  but  the  most  marked  ef- 


HOT    APPLICATIONS  349 

feet  is  seen  in  the  pain  of  inflammation.  The  elficiency  of  tlie  hot  stupes 
may  be  increased  by  adding  one  or  two  tablespoonfuls  of  turpentine  to  the 
hot  water  in  the  basin.  To  some  patients,  however,  the  odor  of  turpentine 
is  disagreeable  and  disturbs  the  stomach  and  with  such  it  should  not  be 
used.  The  disadvantages  of  hot  stupes  are  that  they  have  to  be  changed  very 
frequently  and  that  they  soon  get  the  bedclothing  damp. 

Hot  Pastes.  There  is  a  material  for  external  use,  consisting  of  an  earthy 
silicate  for  a  base  and  having  incorporated  glycerine  and  mild  antiseptics 
with  a  pleasant  odor.  This  is  very  convenient  for  application  to  the  lower 
abdomen  for  it  holds  the  heat  and  moisture  well.  This  material,  with  slight 
variations,  is  put  up  by  a  number  of  firms  and  given  ditferent  names  (gly- 
kaolin,  antiphlogistin,  etc).  Under  one  of  the  trade  names,  it  may  be  pur- 
chased at  any  drug  store  in  one  or  two  pound  cans.  The  method  of  its  ap- 
plication is  as  follows :  Take  off  the  lid  and  set  the  can  in  a  pan  of  hot 
water  on  the  stove  until  the  paste  is  thoroughly  heated.  It  is  then  thin 
enough  to  spread  easily  with  a  spatula  or  knife  or  spoon  handle.  It  is  spread 
directly  on  the  skin  in  a  thick  layer  (about  one-half  inch  thick).  The  whole 
lower  abdomen  is  covered  with  a  thick  layer  of  the  hot  paste,  which  is  cov- 
ered with  a  piece  of  flannel  and  outside  of  this  is  placed  the  hot-water  bag 
or  Japanese  stove  to  keep  it  warm.  The  paste  sticks  tight  to  the  skin  at 
first,  but  after  twenty-four  hours  usually  there  has  been  sufficient  perspiration 
beneath  it  to,  loosen  it  and  cause  it  to  come  off  easily.  It  is  then  removed  and 
a  fresh  layer  applied  immediately.  A  fresh  application  is  made  every  twenty- 
four  hours,  as  long  as  hot  applications  are  desired. 

Flaxseed  Poultice  retains  the  heat  well  and  is  much  used  as  a  home 
remedy  when  hot  applications  are  desired.  It  is  not  nearly  as  convenient  nor 
cleanly  as  the  hot  pastes  but  is  about  as  efficient  if  changed  often  and  kept 
up  for  several  days,  and  is  often  at  hand  when  the  other  things  are  not 
available.  The  flaxseed  poultice  is  made  as  follows:  Take  two  parts  of 
ground  flaxseed  (flaxseed  meal)  and  five  parts  of  boiling  water  and  mix  with 
constant  stirring.  AVhen  mixed,  spread  thick  (one-half  inch)  on  a  piece  of  thin 
muslin  or  cheese-cloth.  Have  the  cloth  large  enough  so  that  you  can  leave 
a  margin  on  each  side  to  fold  over.  The  poultice  should  cover  one-half  the 
cloth  and  the  other  half  can  then  be  laid  over  after  the  margins  are  turned 
in.  If  a  hot-water  bag  or  Japanese  stove  is  at  hand  put  that  over  the 
poultice  to  keep  it  hot. 

Hot  Sitz-bath.  The  patient  sits  in  a  small  tub,  preferably  of  special  de- 
sign, containing  water  enough  to  cover  the  hips,  genitals  and  lower  abdomen. 
The  water  should  be  as  hot  as  the  patient  can  stand  without  discomfort  (105^ 
to  115°).  She  should  remain  in  the  sitz-bath  from  twenty  to  thirty  minutes 
and  then  be  dried  and  put  in  bed.  It  may  be  repeated  daily  or  several  times 
daily,  as  found  most  beneficial.  The  hot  sitz-bath  is  sedative  in  effect  and 
relieves  very  much  the  pain  of  pelvic  inflammation.  In  inflammation  it 
should  be  used  onlv  in  those  cases  where  the  patient  may  make  the  necessary 


350  GYNECOLOGIC    TREATMENT 

movements  without  detriment.     It  is  useful  also  in  helping  the  onset  of  the 
menses  in  amenorrhea  or  suppressed  menses. 

Hot  Moist  Pelvic  Pack.  Instead  of  making  the  hot  applications  to  the 
lower  abdomen  only,  they  may  be  extended  all  around  the  pelvis.  The  whole 
pelvis  is  encased  in  the  hot  stupe  or  compress,  and  over  all  a  large  piece  of 
thin  rubber  cloth  or  table  oilcloth  is  placed.  A  woolen  blanket  also  is 
wrapped  around  the  patient  to  keep  in  the  heat  and  moisture.  This  may  give 
much  relief  from  the  suffering  in  acute  suppression  of  menses,  in  acute  pelvic 
inflammation  and  in  severe  pelvic  neuralgia. 

DRY  HEAT 

Hot-Water  Bag.  The  hot-water  bag  produces  almost  the  same  effect  as 
the  hot  stupes,  and  keeps  hot  a  longer  time  without  change  and  is  much  more 
convenient  to  manij)ulate.  If  the  effect  of  moist  heat  is  desired,  a  hot  stupe 
may  be  applied  and  a  hot-water  bag  placed  over  it  to  keep  it  warm.  If  no 
hot- water  bag  is  at  hand,  a  large  flat  bottle  filled  with  hot  water  may  be  used. 
This  should  be  securely  corked  and  wrapped  in  a  thick  flannel  cloth.  If  no 
suitable  bottle  is  available,  a  plate,  heated  and  wrapped  in  a  flannel  cloth, 
may  be  used,  or  a  stove-lid  or  other  article  that  will  retain  the  heat. 

Japanese  Stove.  This  consists  of  a  small  flat  metal  container,  about  the 
size  of  the  hand,  in  which  is  burned  a  compressed  powder  resembling  char- 
coal. This  little  container  may  be  purchased  at  the  drug  store  for  a  feAv 
cents  and  is  very  convenient  for  applying  dry  heat  or  for  keeping  a  moist 
application  warm.  If  it  is  wished  very  hot,  two  or  three  sticks,  instead  of 
one,  of  the  powder  may  be  lighted  and  dropped  in.  If  one  stove  is  not  large 
enough,  two  or  three  may  be  used. 

Hot-Water  Coil.  This  consists  of  a  coil  of  rubber  tubing  and  a  boiler, 
the  former  being  attached  to  the  latter  by  tubing  in  such  a  way  as  to  cause  a 
constant  circulation  of  hot  water  through  the  coil.  It  is  very  nice  but 
rather  expensive. 

Electrotherm.  This  electric  heating  pad  is  heated  by  a  current  through 
a  cord,  which  is  to  be  attached  in  the  ordinary  electric  light  socket.  This,  like 
the  other  dry  heat  appliances,  may  be  used  alone  for  dry  heat  or  over  a 
moist  application  for  moist  heat. 

Hot-Air  Chamber.  The  apparatus  is  the  same  as  that  for  applying  hot 
dry  heat  to  the  joints  or  other  parts  of  the  body,  the  chamber  for  gynecologic 
cases  being  made  to  fit  about  the  pelvis  and  lower  abdomen.  The  tempera- 
ture that  will  be  borne  varies  with  individuals  and  also  with  the  length  of 
time  employed.  At  first  a  temperature  of  120°  for  twenty  minutes  will  suf- 
fice. After  a  week  or  so  the  patient  may  bear  a  temperature  of  135°  to  150°  for 
45  minutes.  The  temperature  should  not  be  high  enough  to  cause  discomfort 
above  a  slight  tingling  of  the  skin.     The  air  chamber  may  be  heated  with 


COLD   APPLICATIONS  351 

electric  lights,  instead  of  in  the  ordinary  way.  This  is  a  convenient  way  and 
one  in  which  the  heat  is  easily  regulated. 

The  effect  of  the  hot  air  chamber  is  to  cause  marked  redness  of  the  skin, 
free  perspiration  and  a  hastening  of  the  absorj)tion  of  chronic  pelvic  exu- 
dates. Cases  of  chronic  pelvic  inflammation  are  the  ones  suitable  for  treat- 
ment. In  several  cases,  exudates  were  absorbed  in  14  to  20  sittings.  No 
bad  after  effects  w^ere  noted.  Cooling  is  allowed  to  take  place  gradually 
and  the  patient  is  then  dried  and  lies  in  bed  for  an  hour.  It  takes  consider- 
able time,  about  an  hour  to  each  patient,  but  after  the  apparatus  is  once 
started  it  may  be  left  in  the  care  of  an  experienced  nurse. 

Without  any  special  treatment  about  90  per  cent  or  more  of  pelvic  ex- 
udates tend  to  become  absorbed,  if  the  patient  is  kept  quiet.  This  natural 
process  is  hastened  by  laxatives,  hot  douches  and  heat  to  the  abdomen.  This 
particular  method  of  applying  heat  over  a  long  period  is  very  convenient  in 
hospitals  where  the  apparatus  is  kept  on  hand  or  in  homes  where  electricity 
is  available.  In  cases  of  persistent  exudate  without  evidence  of  a  remaining 
focus  of  infection,  it  is  well  to  give  this  method  a  trial. 

Hot  Dry  Pack.  Dry  heat  may  be  applied  all  around  the  pelvis  by 
packing  around  it  hot  water  bags  or  hot  bottles  or  other  containers  for 
maintaining  the  heat,  the  skin  being  well  protected  by  layers  of  flannel. 

COLD  APPLICATIONS 

In  some  cases  cold  gives  more  relief  than  heat,  though  the  cases  in 
which  it  will  do  so  can  not  be  certainly  determined  without  trial.  It  has 
been  stated  that  cold  gives  more  relief  when  the  pain  is  due  to  active  inflam- 
mation and  the  hot  applications  in  other  cases.  In  the  author's  experience, 
that  rule  does  not  hold  good.  On  the  other  hand,  in  the  majority  of  cases, 
pelvic  pain,  inflammatory  or  otherwise,  is  relieved  more  by  hot  applications 
than  by  cold.  Consequently,  the  author's  rule  is  to  use  hot  applications  flrst 
and,  if  they  fail  to  give  relief,  then  the  cold. 

There  are  several  ways  of  applying  cold.  To  get  the  best  sedative  effects 
it  must,  like  the  heat,  be  maintained  continuously,  or  almost  continuously,  for 
several  days. 

Ice  Bag.  The  ordinary  ice  bag  is  a  convenient  and  satisfactory  method 
of  applying  cold.  If  no  regular  ice  bag  can  be  secured,  the  ice  may  be  put 
in  a  hot-water  bag.  The  ordinary  hot-water  bag  fllled  with  ice  does  fairly  well 
as  a  substitute  for  an  ice  bag  but  it  is  not  as  convenient,  for  the  ice  has  to 
be  broken  into  very  small  pieces.  If  no  rubber  bag  of  any  kind  is  at  hand, 
the  broken  ice  may  be  wrapped  in  a  towel  and  placed  in  a  piece  of  table 
oilcloth,  the  edges  and  corners  being  pinned  up  so  that  no  Avater  can  leak 
out. 

Cold- Water  Coil.  One  end  of  the  coil  is  attached  to  a  vessel  of  ice  water 
so  that  the  water  runs  through  it  slowly  and  keeps  it  cold.     The  other  end 


352  GYISTECOLOGIC    TREAT.MEXT 

conducts  the  water  from  the  coil  to  a  waste  bucket  beside  the  bed.  If  the 
hydrant  water  is  cold  enough;  the  tube  leading  to  the  coil  may  be  attached 
to  the  hydrant. 

Cool  Sitz-bath.  This  is  used,  not  as  a  sedative  Ijut  as  an  active  stimu- 
lant to  the  pelvic  organs.  It  is  taken  the  same  as  the  hot  sitz-baths  except 
that  the  temperature  of  the  water  is  70'  to  50^,  and  the  patient  does  not  stay 
in  so  long — only  five  to  twenty  minutes.  It  may  be  given  gradually,  i.e.,  the 
water  is  tepid  at  first  and  gradually  cooled  to  60'  or  50'.  In  some  .cases 
of  amenorrhea  the  cool  sitz-baths  may  prove  more  beneficial  than  the  hot. 
They  should,  however,  be  given  cautiously  and  in.  strong  individuals  only  and 
should  not  be  continued  unless  good  reaction  comes  on.  As  in  a  cool  general 
bath,  the  reaction  should  be  encouraged  and  increased  by  prompt  drjdng  and 
brisk  rubbing. 

COrXTEEIRRITAXT  APPLICATIONS 

Mustard  Plaster.  A  mustard  plaster  or  mustard  poultice  is  applied  over 
the  lower  abdomen  just  long  enough  to  produce  marked  redness  of  the  skin. 
It  should  not  be  left  on  long  enough  to  blister.  This  gives  a  quick  and  wide- 
spread counterirritation  of  the  skin  and  assists  materially  in  relieving  acute 
deep-seated  pain.  The  effect  is  transitory,  however,  and  needs  to  be  con- 
tinued by  the  ordinary  hot  applications.  If  there  is  smarting  of  the  skin 
after  removal  of  the  mustard,  apply  a  layer  of  vaseline  and  a  thin  cloth  under 
the  hot  applications.  The  addition  of  turpentine  to  plain  hot  stupes  is  a  form 
a  counterirritation,  and  in  some  cases  assist  A'ery  much  in  relieving  pain.  Of 
course,  this  should  not  be  applied  to  the  abdomen  in  a  case  where  an  abdom- 
inal operation  may  be  necessary  soon. 

Cantharides  Plaster.  Small  fly  blisters  over  areas  of  persistent  pain 
often  do  much  good  in  cases  of  chronic  pelvic  inflammation  without  marked 
lesion  and  in  cases  of  pelvic  neuralgia.  The  blister  should  be  small,  from  the 
size  of  a  quarter  to  that  of  a  dollar,  and  should  be  carefully  protected  from 
infection  until  healed. 

Cantharides  Collodion  is  very  convenient  for  making  the  small  fly  blis- 
ters. Paint  it  over  the  area  which  it  is  desired  to  blister  and  repeat  after 
twenty-four  hours  if  no  blister  has  appeared. 

Tincture  of  Iodine.  This  is  painted  over  the  ovarian  region  of  the  af- 
fected side  once  or  twice  daily  until  the  skin  becomes  tender.  Then  it  is 
stopped  for  a  few  days  until  the  tenderness  subsides  somewhat,  when  it 
is  renewed.  By  varying  the  application  as  indicated  In-  its  effect  on  the 
skin,  a  constant  mild  counterirritation  may  he  kept  for  weeks,  often  with 
decided  diminution  of  pain. 


VAGINAL   DOUCHES  353 

APPLICATIONS  TO  EXTERNAL  GENITALS,  VAGINA  AND  CERVIX 

VAGINAL  DOUCHES 

The  vaginal  douche  is  used  for  four  purposes — for  simple  cleansing,  for 
astringent  effect,  for  antiseptic  effect  and  for  the  specific  effect  of  hot  water. 

Cleansing'  Douche.  The  simple  cleansing  douche  is  used  when  there  is 
a  troublesome  increase  in  the  normal  muco-epithelial  discharge  or  when  there 
is  a  muco-purulent  discharge  without  pain  or  evidence  of  inflammation  or 
marked  relaxation  of  the  tissues. 

Plain  boiled  water  comfortably  warm  (100°  to  105°)  may  be  used,  but  if 
there  is  much  discharge  it  is  well  to  put  a  teaspoonful  of  ordinary  salt  or  a 
teaspoonful  of  sodium  bicarbonate  to  each  pint  of  water,  or  the  carbolic 
douche  may  be  prescribed.  The  simple  cleansing  douche  may  be  taken  with 
the  fountain  syringe  or  with  the  bulb  (Davidson)  syringe.  It  may  be  taken 
with  the  patient  lying  in  bed  or  in  a  sitting  posture  over  a  vessel.  In  all  vag- 
inal douches  the  point  of  the  syringe  nozzle  should  be  so  large  that  it  can  not 
enter  the  cervical  canal.  Serious  disturbance  and  even  death  has  followed  the 
accidental  injection  of  the  douche  solution  into  the  uterus.  The  point  of  the 
nozzle  should  be  three-fourths  inch  in  diameter,  with  the  end  closed  and  the 
openings  at  the  sides.  When  it  is  necessary  to  use  a  slender  nozzle  (as  in  giving 
a  douche  to  a  virgin)  it  should  be  very  short. 

Vaginal  douches  should  be  used  only  when  there  is  some  definite  indica- 
tions for  them.  In  healthy  women  the  constant  use  of  douches  or  the  routine 
use  of  them  for  indefinite  periods,  is  not  advisable.  They  are  not  required 
for  mere  cleanliness,  in  fact,  they  interfere  in  a  measure  with  the  normal 
germicidal  vaginal  contents,  which  nature  has  provided  to  keep  the  vagina 
in  a  healthy  condition  and  to  protect  the  structures  above. 

Astringent  Douche.  The  astringent  douche  is  used  when  the  vaginal  walls 
are  lax  and  atonic  or  in  the  various  erosions  and  other  chronic  inflammatory 
lesions  of  the  cervix  and  in  cases  where  there  is  soft,  bleeding  tissue  about 
the  cervix  or  vagina. 

As  a  mild  astringent  and  sedative  douche  with  some  antiseptic  effect,  a 
solution  of  aluminum  acetate  is  exceptionally  efficient.  Dissolve  the  powder 
in  boiling  water,  and  then  allow  it  to  cool  sufficiently  for  the  douche.  It  is 
rather  difficult  to  dissolve,  that  from  some  manufacturers  more  so  than  from 
others.  The  aluminum  acetate  is  excellent  to  use  in  connection  with  the  hot 
douche,  the  last  two  quarts  of  the  hot  irrigating  douche  being  saturated  with  it. 

When  a  stronger  astringent  effect  is  desired,  the  zinc  sulphate  and  alum 
douche  or  the  tannic  acid  douche  may  be  used.  These  strong  astringent 
douches  are  used  principally  in  cases  of  soft,  bleeding  tissue  in  the  vagina  or 
in  cancer  of  cervix  or  vaginal  wall.  They  may  be  used  also  with  benefit  in 
relaxation  of  vaginal  tissues  and  in  erosions  and  other  chronic  inflammatory 
lesions  of  the  cervix,  in  cases  where  it  is  impracticable  to  use  the  hot  douche. 


354  GYNECOLOGIC    TREATMENT 

Care  must  be  taken  that  the  solution  does  not  irritate  the  vaginal  wall.  It  is 
well  to  begin  with  a  weak  solution  and  advance  to  the  stronger  as  toleration 
is  established. 

Astringent  douches  should  be  taken  with  the  patient  in  the  horizontal 
posture,  preferably  with  the  hips  elevated  on  the  bed-pan,  as  described  in  the 
technic  of  the  long  hot  douche  (Fig.  425). 

Antiseptic  Douche.  The  antiseptic  douche  is  used  in  those  cases  of  puru- 
lent discharge  or  muco-purulent  discharge  in  which  the  admixture  of  pus  is 
so  prominent  that  an  active  germicidal  effect  is  important.  One  of  the  best 
of  the  germicides  for  making  a  strongly  antiseptic  douche  is  the  only  standby, 
hydrarg.  bichloride,  used  in  the  strength  of  about  1-5000  or,  where  a  weak  anti- 
septic is  desired,  1-10,000.  Some  state  that  it  is  dangerous  to  use  such  a  strong 
antiseptic  as  a  vaginal  douche  on  account  of  the  danger  of  poisoning.  This 
is  hardly  probable,  however,  with  the  strength  mentioned  and  under  pre- 
cautions. The  author  has  prescribed  it  freely  for  a  number  of  years  and  he 
noticed  no  untoward  results.  The  author  is  careful  not  to  use  it  when  there 
is  a  large  raw  surface  in  the  vagina  or  when  there  is  an  opening  communicat- 
ing with  a  large  pelvic  abscess  cavity  or  when  the  cervical  canal  stands  open 
so  that  the  solution  might  easily  pass  into  the  uterus.  Absorption  from  the 
intact  vagina  is  not  probable.  In  prescribing,  it  is  well  to  have  the  con- 
centrated solution  colored  so  no  mistakes  will  arise,  for  it  is  a  violent  poison. 

Another  efficient  and  very  satisfactory  douche  is  formol,  1-5000  to  1-3000. 
Formol,  as  purchased  in  the  drug  stores,  is  a  40  per  cent  solution  of  formalde- 
hyde gas.  Formol  is  a  very  strong  antiseptic  and  must  be  used  in  weak  solu- 
tion or  it  will  cause  irritation.  Five  to  ten  drops  to  two  quarts  of  warm 
water  is  usually  sufficient,  though  for  special  conditions  the  strength  may  be 
increased  with  some  patients. 

Hot  Vaginal  Douche.  The  hot  vaginal  douche  is  cleansing  and  may  be 
made  antiseptic  or  astringent,  but  its  special  and  distinct  effects  are  the  relief 
of  pain,  the  limitation  of  inflammation,  the  hastening  of  absorption  of  exudates 
and  the  toning  up  of  relaxed  tissues.  These  effects  are  brought  about  by 
the  prolonged  application  of  hot  water  to  the  vaginal  walls  and  cervix. 

To  get  the  best  effect,  it  is  essential  that  particular  attention  be  given 
to  certain  details  of  its  administration.  These  details  are  usually  carried 
out  in  an  incomplete  way,  for  the  importance  of  their  full  employment  is  not 
at  all  appreciated  by  the  patient  and  as  a  rule  only  partially  by  the  physician. 
Hence,  ordinarily,  the  hot  douche  amounts  to  little  more  than  a  cleansing 
douche,  the  specific  effect  of  the  heat  being  almost  wholly  missed. 

This  is  an  important  subject  for,  given  properly,  the  hot  douche  is  one 
of  the  most  effective  non-operative  measures  used  in  the  treatment  of  gyneco- 
logic diseases.  Furthermore,  it  is  an  inexpensive  and  simple  measure,  the 
necessary  articles  costing  but  little,  and  the  douche  may  be  given  to  the  pa- 
tient by  any  woman  of  ordinary  intelligence,  if  definitely  instructed.  It 
has  also  the  least  possibilities  of  harm  of  the  various  methods  of  local  treat- 


VAGINAL   DOUCHES  355 

meiit  and  is  the  least  disturbing  to  the  anatomy  and  physiology  of  the  parts. 
The  specific  effect  of  the  hot  douche  was  recognized  more  than  forty  years 
ago  by  that  prince  of  clinical"  investigators,  T.  A.  Emmet,  and  clearly 
set  forth  in  his  splendid  work  published  in  1879,  from  which  the  following 
quotation  is  taken: 

"It  has  been  stated  that  the  sympathetic  system  of  nerves  presides  over 
nutrition  and  the  organs  of  generation  and  that  every  blood  vessel,  to  the 
minutest  capillary,  is  covered  by  a  network  of  nerve  filaments  communicating 
(lirictly  with  the  different  ganglia.  "When  nutrition  is  impaired,  there  is 
naturally  a  want  of  tone  in  the  blood  vessels.  It  is  only  by  exciting  reflex 
action  through  these  nerves  that  the  necessary  tonicity  will  be  restored. 

"We  have  three  agents  for  exciting  this  reflex  action,  viz.,  electricity, 
cold  and  heat. 

"Electricity  exerts  a  decided  effect  during  the  time  of  the  passage  of  the 
current,  but  the  impression  is  too  transitory  and  the  agent  is  only  to  be  relied 
upon  as  a  valuable  adjuvant. 

"Cold  is  a  prompt  excitor  of  reflex  action,  by  which  the  vessels  con- 
tract, but  on  reaction  taking  place  the  parts  will  become  more  congested  than 
before,  with  both  the  arteries  and  veins  distended. 

"Heat,  unless  at  a  temperature  that  would  destroy  the  p.arts,  does  not  act 
as  promptly  in  causing  this  contraction  as  either  electricity  or  cold.  In  fact, 
its  immediate  effect  is  to  cause  relaxation  and  to  increase  the  congestion  of 
the  parts,  but  if  its  application  be  prolonged,  reaction  ensues  and  contraction 
takes  place.  In  other  words  the  reaction  from  heat  is  contraction.  The  capil- 
laries are  excited  to  increased  action  and  as  they  contract  from  the  stimulus 
of  these  nerves,  the  tonic  effect  extends  to  the  coats  of  the  larger  vessels, 
their  caliber  in  turn  becomes  lessened  and  with  this  approach  to  healthy  action 
the  congestion  is  diminished.  The  popular  belief  is  that  heat  relaxes  and  in- 
creases the  congestion  of  the  parts,  and  such  indeed  is  the  case  at  first.  But 
a  hot  poultice  is  never  applied  with  the  object  of  increasing  the  congestion, 
but,  as  any  'old  wife'  would  express  it,  to  draw  the  'fire'  or  inflammation  out — 
in  other  words  it  lessens  the  congestion  by  stimulating  the  blood  vessels  to 
contract.  That  such  is  the  effect,  from  the  continued  use  of  a  poultice,  is  fa- 
miliar to  everyone  and  is  shoT\ai  by  the  blanched  and  shriveled  appearance 
of  the  tissues  after  its  removal.  The  hands  and  arms  of  a  washer-woman  be- 
come swollen  at  first,  from  the  increased  flow  of  blood  when  in  hot  water,  but 
the  fact  is  quite  as  familiar  that  they  afterwards  become  markedly  shrivelled. 

"To  place  the  hands  in  cold  water  will  at  once  cause  the  skin  to  shrivel, 
as  the  vessels  are  stimulated  to  contract,  but  we  are  all  familiar  with  the 
fact  that  reaction  promptly  comes  on,  and  a  larger  quantity  of  blood  returns 
to  the  parts  than  was  driven  out.  The  immediate  effect  of  cold,  therefore,  is 
contraction,  and  with  reaction  comes  dilatation;  but  the  reverse  is  true  of 
heat,  which  causes  at  first  dilatation  followed,  however,  by  contraction. 

"AVith  these  practical  points  before  us,  we  resort  t«  the  prolonged  use 


356  GYNECOLOGIC    TREATMENT 

of  hot  water,  by  vaginal  injections,  to  gradually  bring  about  the  required 
contraction  and  tone  in  the  pelvic  vessels.  Whenever  inflammation  exists  we 
have  congestion  of  the  arterial  capillaries.  .  .  .  The  congestion  may  be  either 
venous  or  arterial.  This  remedy  is  not  to  be  considered  a  '  cure  all, '  but  one  of 
the  most  valuable  adjuvants,  under  all  circumstances,  to  other  means. 

''If  a  vaginal  injection  has  been  properly  administered,  the  mucous 
membrane  will  be  found  blanched  in  appearance,  and  the  usual  size  of  the 
canal  lessened  in  calibre,  as  after  the  use  of  a  strong  astringent  injection.  As 
the  patient  lies  on  the  back  with  her  hips  elevated,  the  action  of  gravity  will 
be  brought  into  play,  by  which  the  veins  will  be  rapidly  emptied  sufficiently 
to  relieve  the  over-distention.  When  in  this  position  also,  the  vagina  will 
become  fully  distended  by  the  weight  of  water  and  kept  so,  since  only  the 
surplus  amount  can  run  off  into  the  bed-pan  beneath.  The  hot  water  will 
then  be  in  contact  with  every  portion  of  the  mucous  membrane  under  which 
the  capillaries  lies.  The  vessels  going  to  and  from  the  cervix  and  body  of 
the  uterus  pass  along  the  sulcus  on  each  side  of  the  vagina,  and  their  branches 
enclose  the  vagina  in  a  complete  network.  ...  If  then  we  are  able  to  cause  the 
vessels  of  the  vagina  to  contract,  through  the  stimulus  of  the  hot  water,  we 
can  directly  or  indirectly  influence  a  large  part  of  the  pelvic  circulation.  It 
is  most  important  to  appreciate  the  necessity  for  elevating  the  hips,  by  which 
plan  so  large  a  portion  of  the  venous  blood  becomes  drawn  off  by  gravitation. 
If  the  stimulus  of  the  hot  water  is  then  applied,  so  as  to  cause  the  vessels  to 
contract  still  more,  we  will,  for  a  time  at  least,  have  the  pelvic  circulation 
reduced  almost  to  a  natural  condition.  In  order  to  allow  the  condition  of  con- 
traction to  be  as  prolonged  as  possible,  I  generally  direct  the  injection  to  be 
given  at  night,  in  bed,  just  as  the  patient  is  ready  to  retire.  Thus,  by  con- 
stantly causing  these  vessels  to  contract,  and  by  resorting  to  every  other 
means  of  lessening  the  supply  of  blood  in  the  pelvis,  we  will  succeed  eventu- 
ally in  securing  a  proper  vascular  tone. 

"No  plan  of  treatment  could  be  more  rational  or  appeal  more  forcibly 
to  the  good  judgment  of  everyone.  But,  unfortunately,  from  a  neglect  of  de- 
tails, it  is  rare  that  the  slightest  beneflt  is  derived  from  these  injections,  al- 
though so  many  years  have  elapsed  since  the  profession  has  been  fully 
instructed  as  to  their  mode  of  action.  For  fifteen  years  at  least,  I  have  been 
experimenting  by  different  methods  in  the  use  of  hot  water,  and  have  had 
during  that  time  as  large  a  number  of  cases  as  would  be  likely  to  be  at 
the  service  of  anyone,  and  I  have  arrived  at  the  conclusion  that  it  is  an  im- 
possibility for  a  patient  to  give  these  injections  to  herself  so  as  to  derive  their 
full  benefit.  Not  the  slightest  advantage  is  received  from  them  when  admin- 
istered with  the  patient  in  the  upright  position,  or,  as  is  the  usual  method, 
while  seated  over  a  bidet,  for,  given  thus,  the  water  does  not  dilate  the  pas- 
sage but  returns  along  the  nozzle  of  the  syringe.  I  have  found  that  the  best 
method  of  all  is  to  have  the  injections  given  while  the  patient  is  placed  on 
her  knees  and  elbows  or  chest.    In  this  position  we  have  the  assistance  both 


VAGINAL   DOUCHES  357 

of  gravity  and  the  pressure  of  the  atmosphere  to  empty  the  pelvic  veins,  while 
the  water  is  able  to  act  on  a  much  larger  surface  of  the  vagina  than  it  is  when 
the  patient  is  in  any  other  position.  But  this  position  is  a  difficult  one  to 
assume,  since  those  who  are  in  the  greatest  need  of  hot  water  have  not  the 
strength  to  remain  in  it  long  enough  to  accomplish  the  purpose,  and  consider- 
able difficulty  is  also  experienced  in  keeping  the  patient  dry.  This  latter 
difficulty,  however,  can  in  a  measure  be  overcome  by  using  a  funnel-shaped 
receptacle,  with  an  India  rubber  tube  attached  to  the  smaller  end,  the  two 
sides  being  indented  sufficiently  to  enable  the  patient  to  keep  it  in  place  by 
keeping  the  thighs  together.  But  for  the  larger  number  of  cases,  the  position 
on  the  back,  with  a  bed-pan  to  elevate  the  hips,  will  be  found  the  most  con- 
venient. Few  women  are  so  situated  as  to  be  unable  to  get  someone  to  ad- 
minister the  injection  properly,  and  the  inconvenience  of  soliciting  aid  is  a 
trifling  one  considering  the  benefit  to  be  derived  from  it,  since  experience  has 
shown  that,  unless  the  details  can  be  carried  out  fully,  the  process  only  in- 
volves a  waste  of  time  and  a  tax  on  the  strength  of  the  patient. 

''The  temperature  and  quantity  of  water  are  to  be  varied  according  to  cir- 
cumstances. When  treating  the  early  stages  of  inflammation,  it  is  necessary  that 
the  temperature  should  be  elevated  rapidly  from  that  of  blood  heat  to  110°, 
or  to  as  high  a  degree  as  can  be  borne  by  the  patient,  and  that  the  injection 
should  be  often  repeated.  For  ordinary  use,  a  gallon  of  water  at  two  or 
^ree  degrees  above  blood  heat  is  generally  sufficient,  but  the  temperature 
^^fcJ[^P!^nnmined  at  the  highest  point  by  the  addition  of  hot  water  from 
j^^^to  time.  The  hour  of  bedtime  is  usually  the  best  in  which  to  seek  for 
the  beneficial  effects  of  hot  water  on  the  reflex  system  in  allaying  the  local 
irritation,  for  prolonged  vaginal  injection  at  a  high  temperature  will  often, 
when  given  by  an  experienced  hand,  act  with  more  promptness  than  an  ano- 
dyne in  allaying  the  nervousness  and  sleeplessness  of  a  hysterical  woman.  I 
have  frequently  known  a  patient,  after  being  well  rubbed  and  having  received 
an  injection,  to  fall  asleep  before  the  nurse  had  completed  the  process  and  to 
be  so  overcome  with  drowsiness  as  to  be  but  little  disturbed  on  removing  the 
bed-pan. 

''In  rare  instances  and  from  a  condition  I  am  unable  to  explain,  cases 
are  met  with  where  a  sensation  of  weight  and  an  uncomfortable  feeling  are 
experienced  after  an  injection  of  water  at  the  usual  temperature.  In  some 
instances  so  much  disturbance  resulted  that  occasionally  I  was  obliged  to 
abandon  its  use.  But  I  have  long  since  ascertained  that  the  injection  is  well 
borne  at  a  lower  temperature,  generally  about  95°,  and  that  after  a  week  or 
two  the  temperature  can  be  gradually  increased. 

"This  'cooking  process,'  as  it  has  been  facetiously  termed,  is  rendered 
easier  by  the  use  of  ivory  or  some  other  nonconducting  material,  for  the 
nozzle  of  the  syringe,  since  the  patient  suffers  more  discomfort  from  the 
heated  metal  surface  of  the  ordinary  nozzle  coming  in  contact  with  the  out- 


358  GYNECOLOGIC    TREATMENT 

let  of  the  vagina  than  from  any  degree  of  heat  in  the  water  which  it  is  ad- 
visable to  employ. 

"To  the  injection  (generally  to  the  last  pint)  may  be  added  glycerine, 
chlorate  of  potash,  chloride  of  sodium,  carbonate  of  soda,  borax,  castile  soap, 
sulphate  of  copper,  muriate  of  ammonia,  brewer's  yeast,  permanganate  of 
potassa,  carbolic  acid  or  any  other  remedy  which  may  seem  to  be  indicated. 

*'As  the  patient  improves  in  health,  the  quantity  of  water  for  the  injec- 
tion may  be  lessened  and  the  temperature  gradually  lowered  and  then  dis- 
continued. But  for  some  months  it  would  be  prudent,  for  a  few  days  after 
each  period,  to  resume  the  injections  at  a  degree  or  two  above  blood  heat, 
and  to  have  recourse  to  them  whenever  their  use  should  seem  indicated  to 
counteract  the  effect  of  some  imprudence. 

"I  do  not  claim  to  be  the  first  person  under  whose  direction  a  vagina 
was  ever  washed  out  with  warm  water,  but  I  do  claim  to  be  the  first 
to  use  the  agent  in  a  systematic  manner,  for  the  treatment  of  the  diseases  of 
women,  and  to  have  done  so  with  a  definite  purpose."* 

Directions  for  the  Hot  Vaginal  Douche 

In  prescribing  the  hot  douche,  take  pains  to  give  explicit  directions  on 
the  following  points : 

1.  Articles  Required.  Direct  the  patient  to  buy  a  yard  of  thin  oilcloth, 
a  douche  pan,  a  fountain  syringe,  a  bath  thermometer  and  a  four-ounce  bottle 
of  lysol. 

The  patient  wishes  the  most  effective  treatment,  not  half-Avay  measures. 
These  articles  cost  but  little  and  are  necessary  to  the  proper  care  of  the 
case. 

The  piece  of  oilcloth  is  to  be  placed  under  the  douche  pan  to  thoroughly 
protect  the  bed.  It  does  very  well.  A  piece  of  white  rubber  cloth  is  nicer  but 
a  little  more  expensive. 

A  very  convenient  form  of  douche  pan  is  that  shown  in  Fig.  425.  It  should 
have  an  opening  for  attachment  of  rubber  tubing  to  conduct  the  water  to  a 
vessel  beside  the  bed,  so  that  when  desired,  several  gallons  of  water  may  be 
used  without  emptying  the  douche  pan.  This  pan  holds  a  large  quantity 
of  water  and  is  easily  cleansed,  and  by  closing  the  outlet  with  the  screw  cap 
it  may  be  used  as  an  ordinary  bed-pan.  A  douche  pan  of  this  or  some  similar 
style  can  be  purchased  for  a  small  amount  and  is  just  as  much  a  necessity  in 
the  proper  treatment  of  the  case  as  medicines  that  cost  more. 

The  fountain  syringe  should  be  of  good  size  (3  or  4  qts.),  the  syringe- 
nozzle  having  an  end  three-fourths  inch  in  diameter  and  with  the  openings 
at  the  sides  (Fig.  449).  The  nozzle  is  kept  in  2  per  cent  lysol  solution  (two 
teaspoonfuls  to  a  pint  of  boiled  water)  when  not  in  use.     Immediately  after 


^Principles   and   Practice   of  Gynecology,   by   Thomas   Addis   Emmet,   M.D. 


VAGINAL   DOUCHES  359 

US©  each  time,  it  is  washed  out  with  a  stream  of  water  and  then  dropped  into 
the  antiseptic  solution. 

The  bath  thermometer  should  register  as  high  as  120°  F.  It  is  kept 
wrapped  in  a  clean  towel.  Each  time  before  use  it  is  cleansed  in  the  lysol 
solution.  After  use  it  is  again  cleansed  in  the  lysol  solution,  dried  and 
wrapped  in  towel. 

The  antiseptic  is  used  for  cleansing  the  douche  nozzle  and  the  thermom- 
eter, and  for  mixing  with  the  last  two  quarts  of  the  douche  water  when  it  is 
desirable  to  do  so.  Any  antiseptic  desired  may  be  used.  Lysol  is  easily  ob- 
tained, may  be  mixed  in  approximately  the  required  proportions  very  easily, 
does  not  corrode  when  mixed  in  a  metal  vessel,  is  of  such  color  and  odor  that 
it  is  not  likely  to  be  mistaken  for  something  else  and  does  about  as  well  as 
anything  so  far  as  antiseptic  effect  is  concerned.  For  a  douche  use  one-half 
per  cent  (one  teaspoonful  to  the  quart).  If  an  astringent  effect  is  desired,  use; 
alum  (two  teaspoonfuls  to  the  last  two  quarts)  or  aluminum  acetate  (one' 
teaspoonful  to  the  last  two  quarts),  instead  of  the  lysol.  If  a  still  stronger 
astringent  effect  is  desired,  the  zinc  sulphate  douche  or  the  tannic  acid  douche 
may  be  used. 

2.  Have  some  one  give  the  douche  as  follows: — Scald  out  the  douche 
bag  and  tubing  with  boiling  water  and  hang  it  about  the  feet  above  the 
level  of  the  bed.  Get  a  tea-kettle  of  boiling  water  and  a  large  pitcher  of 
warm  water,  as  warm  as  the  douche  may  be  comfortably  begun  with  (about 
105°  by  the  bath  thermometer).  Put  the  piece  of  thin  oilcloth  on  the  bed, 
and  on  this  an  ironing  board.  Put  the  douche  pan  on  the  lower  part  of  the 
board  and  a  quilt  on  the  upper  part,  to  make  it  comfortable  for  the  patient, 
and  a  pilloAv  for  her  head.  If  the  upper  edge  of  the  douche  pan  is  uncom- 
fortable, cover  it  with  a  folded  towel.  The  tube  of  the  douche  pan  leads  into 
a  bucket  beside  the  bed. 

When  the  patient  is  arranged,  the  hips  should  be  considerably  higher  than 
the  rest  of  the  body  (Fig.  425).  Take  the  douche  nozzle  out  of  the  lysol  solu- 
tion, rinse  off  the  lysol  in  the  pitcher  of  douche  water,  attach  the  nozzle  to 
the  douche  tubing  and  introduce  it  into  the  vagina.  Pour  some  of  the  warm 
water  from  the  pitcher  into  the  douche  bag  and  allow  it  to  run.  If  some 
air  runs  from  the  douche  tube  into  the  vagina,  that  is  beneficial  for  it  helps 
to.  separate  the  walls.  As  the  patient  can  take  the  water  warmer  and 
warmer  increase  the  temperature,  ])ringing  it  up  to  115°  if  not  too  uncom- 
fortable. 

Keep  up  the  hot  irrigation,  ordinarily,  for  thirty  minutes  or  more,  using 
as  much  water  as  necessary  to  maintain  the  irrigation  for  that  length  of  time. 
The  water  runs  slowly  (only  tAvo  or  three  feet  elevation)  and  three  or  four 
gallons  is  usually  enough. 

3.  If  it  is  desired  to  make  the  latter  part  of  the  douche  especially  astrin- 
gent, as  when  the  parts  are  relaxed  and  atonic,  a  suitable  chemical  is  added. 


360 


GYNECOLOGIC    TREATMENT 


The  aluminum  acetate  is  excellent  for  this  purpose,  a  teaspoonful  of  the 
powder  beiiii^  dissolved  in  the  last  two  quarts  of  the  irrigating  fluid.  If  a 
strong  antiseptic  effect  is  needed,  as  in  a  case  of  purulent  discharge,  the 
required  antiseptic  is  added  to  the  last  two  quarts  of  the  hot  water. 

In   inflammation    (subacute   or   chronic)    considerable   additional   benefit 
is  secured  by  introducing  to  the  top  of  the  vagina,  immediately  after  the 


Fig.  425.  Patient  arranged  for  the  Long  Hot  \'aginal  Douche.  Notice  that  the  patient's  hips  are 
elevated  and  that  the  douche  pan  has  an  outlet  tube  leading  into  a  bucket  beside  the  bed.  The  douche 
nozzle  has  a  thick  end  and  the  openings  are  at  the  side,  so  that  there  is  no  possibility  of  the  water  being 
forced  into  the  uterine  cavity.  The  douche  bag  may  be  hung  at  any  height  required  to  give  the  desired 
rate  of  flow. 


douche,  a  vaginal  capsule  containing  a  tampon  with  the  upper  end  saturated 
with  some  glycerine  preparation  (ichthyol-giycerine  or  boro-glycerine).  This 
tampon  is  left  in  place  from  twelve  to  tM^enty-four  hours,  when  it  is  removed 
and  the  douche  repeated.  This  is  an  excellent  method  of  treating  subacute 
or  chronic  pelvic  inflammation  and  also  acute  exacerbations  of  the  same. 


LOCAL    TREATMENT  361 

4.  After  the  Douche,  the  patient  slides  over  to  another  part  of  the  bed 
while  the  douche  pan,  etc.,  is  being  removed,  and  should  remain  quiet  for  at 
least  an  hour. 

5.  The  Frequency  with  which  the  douche  should  be  repeated  varies  with 
the  case.  In  chronic  inflammation,  when  the  patient  is  up  and  at  work  and 
suffering  but  little,  once  a  day  may  be  sufficient.  In  such  a  case  the  prefer- 
able time  is  in  the  evening,  as  the  patient  is  then  in  bed  for  several  hours 
afterwards. 

In  cases  of  more  severity  or  where  the  one  douche  does  not  produce 
satisfactory  results,  a  douche  in  the  forenoon  may  be  added — the  patient  re- 
maining in  bed  at  least  one  hour  afterward. 

In  the  cases  where  the  patient  is  confined  to  bed,  the  douche  is  given, 
ordinarily  twice  daily.  In  severe  cases  of  acute  pelvic  inflammation,  after  it 
is  seen  that  the  uterus  is  clean  and  draining  and  any  other  focus  of  infection 
opened,  it  may  be  beneficial  to  give  the  hot  douche  every  six  hours  and  in 
some  exceptional  cases,  it  is  advisable  to  keep  up  an  almost  constant  irriga- 
tion of  the  parts  for  some  days. 

6.  This  hot  vaginal  douche,  with  its  specific  effect,  is  beneficial  in  prac- 
tically all  inflammatory  conditions  of  the  pelvis,  in  relaxation  and  want  of 
tone  in  the  pelvic  tissues,  in  pelvic  congestion  and  in  pelvic  neuralgia.  In 
these  conditions  it  must  not  be  depended  on  to  the  exclusion  of  other  neces- 
sary measures,  operative  and  non-operative,  but  it  is  to  be  used  in  conjunction 
with  these,  as  indicated  by  the  requirements  of  the  particular  case. 

Where  many  gynecologic  cases  are  treated,  it  is  well  to  have  a  printed 
slip  to  give  each  patient  who  is  to  take  the  douche,  setting  forth  definitely, 
in  a  few  plain  words,  the  necessary  directions.  By  having  this  to  refer  to, 
the  person  who  gives  the  douche  will  give  it  much  more  nearly  as  it  should 
be  given  and  therefore  much  more  effectively. 

LOCAL    TREATMENT 

Before  taking  up  the  details  of  the  office  treatment  of  gynecologic  dis- 
eases, it  would  be  Avell  to  get  a  clear  idea  of  what  good  can  be  done  and 
what  harm  can  be  done  by  such  treatment. 

The  importance  of  ordinary  office  treatment  is,  on  the  Avhole,  still  rated 
much  above  its  actual  value.  This  statement  applies  especially  to  the  appli- 
cation of  medicines  to  the  vaginal  walls,  to  the  cervix  and  to  the  interior  of 
the  uterus.  In  some  affections  for  which  this  method  of  treatment  is  generally 
and  persistently  employed,  it  does  no  good  and  much  harm. 

There  is,  however,  no  warrant  for  those  wholesale  condemnatory  state- 
ments made  from  time  to  time  which,  reduced  to  their  essence,  mean  that 
when  any  pelvic  disturbance  is  severe  enough  to  require  treatment,  it  re- 
quires operation.  Such  teaching  is  very  far  from  the  truth  and  is  almost,  if 
not  fully,  as  erroneous  in  theory  and  deplorable  in  results  as  the  former  teach- 


362  GTXECOLOGIC    TREAT^IEXT 

ing  that  "local  treatment"  Avas  the  most  important  measure  in  the  handling 
of  patients  Avith  pelvic  disease.  Happily  the  treatment  of  gynecologic  dis- 
eases is  no  longer  based  upon  obscure  theories  and  opinions  empirically  ex- 
pressed, but  upon  the  rational  application  of  kno^vn  remedies  to  demonstrated 
pathologic  conditions.  Though  there  is  still  much  to  be  learned  and  much 
that  is  obscure,  as  there  always  ^vill  be  about  a  subject  so  intimately  con- 
nected with  the  mysterious  processes  of  life,  the  essential  features  of  most  of 
the  diseases  and  the  main  effects  of  the  principal  methods  of  treatment  are 
open  to  the  understanding  of  all  who  will  give  the  necessary  time  and  study 
to  the  subject. 

Critically  reviewing  the  demonstrated  pathologic  changes  present  in 
the  various  gynecologic  affections,  it  is  evident  that  in  a  considerable  pro- 
portion of  the  serious  diseases,  effective  treatment  is  necessarily  operative, 
for  the  al3normal  changes  are  of  sucli  nature  that  they  can  be  iirfiueuced  only 
by  direct  handliug  and  treatment  of  the  affected  organs.  On  the  other  hand, 
there  are  many  conditions  that  may  be  much  influenced  by  non-operative 
measures  carried  out  at  home,  such  as  attention  to  general  health,  internal 
medicine,  special  exercises,  posture,  hot  or  cold  external  applications,  hot 
vaginal  douches,  etc.  Much  eff'ect  is  exercised  also  over  certain  condi- 
tions, by  local  treatment  in  the  office — pessaries,  tampons,  packings,  pressure 
ti-eatment.  massage,  dilatation  and  A'arious  medicinal  applications  to  the 
vagina  or  cervix  or  within  the  uterus. 

Xo  one  of  these  methods  should  be  used  until  sufficient  knowledge  has 
been  obtained  to  shoAv  what  the  principal  effects  of  that  method  are  and  in 
what  conditions  we  in&y  reasonably  expect  decided  benefit  from  such  effects. 

The  method  just  now  under  consideration  is  the  application  of  concen- 
trated solutions  to  the  cervix  uteri,  the  vaginal  wall  or  the  external  genitals. 

What  good  can  such  applications  do? 

1.  They  may  exercise  an  antiseptic  or  an  astringent  or  an  anesthetic  or 
an  irritating  effect,  limited  to  the  surface  on  which  they  are  applied. 

2.  They  may  destroy  tissue   (cautery). 

3.  They  may  draw  off  fluid  from  tissues  adjacent  to  the  vaginal  vault 
(hygroscopic  effect),  as  in  the  use  of  glycerine  in  various  combinations.  This 
may  diminish  the  pain  (interstitial  pressure)  of  an  inflammatory  or  edematous 
infiltration  and  possibly  assist  nature  in  limiting  the  inflammation  and  hasten- 
ing absorption.  This  effect  is  very  desirable,  but  in  acute  and  subacute  cases 
its  beneficial  effect  is  more  than  overbalanced  hy  the  trips  to  the  office.  In 
such  cases  the  effect  may  l^e  more  advantageously  secured  by  having  the 
tampon-capsules  used  at  home,  immediately  after  the  douche.  Occasionally, 
in  the  case  of  a  chronic  exudate,  when  the  patient  can  get  about  without 
disturliance.  it  may  be  used  with  decided  effect  in  office  work. 

■4.  They  may  possibly  influence  deep  pains  by  counterirritation  at  the 
vaginal  vault.  This  is  applicable  only  in  eases  of  chronic  exudate  or  pelvic 
neuralgia,   and   even   in  these   it   is   of  dnulitful   utility.      AVhere   the   decidec] 


LOCAL    TREATMENT  363 

relief  of  pain  that  sometimes  follows  counterirritation  at  the  vaginal  vault  is 
due  to  the  mechanical  drawing  of  the  blood  from  the  adjacent  tissues  to  the 
dilated  vessels  of  the  vaginal  surface,  or  to  a  reflex  deep  anemia  from  the  irri- 
tation of  surface  nerve-filaments,  or  to  a  purely  sensory  effect  on  the  deeper 
nerves  by  irritation  of  the  corresponding  superficial  nerves,  the  author  is  not 
prepared  to  say.  Possibly  it  is  not  due  to  any  of  these  but  to  some  other  factor 
in  the  treatment  (pressure,  cleansing,  posture). 

Formerly  much  importance  Avas  attached  to  counterirritation  at  the 
vaginal  vault,  and  a  woman  with  pelvic  inflammation  could  hardly  be  consid- 
ered initiated  into  treatment  until  the  vaginal  vault  and  cervix  had  been 
painted  with  Churchill's  tincture  of  iodine.  It  is  not  so  often  used  now,  for 
we  have  more  effective  measures. 

What  harm  can  such  applications  do? 

1.  May  cause  the  patient  to  come  to  the  office  Avhen  the  dressing  and 
coming  do  more  harm  than  the  application  does  good.  This  is  true  of  all 
acute  inflammations  (even  vaginal  and  vulvar)  and  of  practically  all  sub- 
acute inflammations  of  the  uterus  and  deep  pelvic  structures. 

2.  May  cause  postponement  of  effective  treatment,  by  holding  out  false 
hope,  until  the  disease  is  much  more  difficult  of  cure  or  is  past  cure.  This 
applies  to  chronic  inflammations  of  the  .corpus  uteri  and  peritoneal  struc- 
tures, to  deep-seated  inflammatory  troubles  of  the  cervix  uteri  and  to  begin- 
ning cancer  of  the  uterus. 

3.  May  convert  a  neurasthenic  or  hysteric  into  a  confirmed  invalid  by 
fixing  attention  upon,  and  exaggerating  the  importance  of,  some  trivial  local 
disturbance.  In  such  patients  the  frequent  calling  of  the  attention  to  some 
minor  disturbance  in  any  part  of  the  body  is  deleterious  and  particularly  so 
if  the  disturbance  is  in  the  genital  tract,  for  the  importance  of  minor  disturb- 
ances there  is  greatly  overrated  in  the  minds  of  people  generally.  For  this 
reason,  in  patients  with  neurasthenic  or  hysteric  tendency,  it  is  advisable  to 
avoid  repeated  local  treatments,  even  in  some  conditions  where  otherwise  one 
would  feel  that  they  might  be  beneficial.  Occasionally  local  treatment  of  an  un- 
important lesion  two  or  three  times,  principally  for  psychic  effect  and  to  gain 
the  patient's  confidence  by  letting  her  see  that  you  appreciate  all  that  is  there, 
is  beneficial.  Usually,  however,  the  same  effect  is  better  accomplished  by  a 
thorough  examination  and  then  an  unequivocal  dismissal  of  those  organs 
from  the  list  of  damaged  structures. 

The  concentrated  solutions  used  for  application  to  the  vaginal  walls  or 
cervix,  are  applied  through  a  speculum  by  means  of  a  pledget  of  cotton  held 
with  a  uterine  dressing  forceps,  or  by  means  of  a  cotton-wrapped  applicator. 
These  solutions  may  be  divided  into  several  groups,  according  to  effects.  The 
author  does  not  give  all  the  solutions  under  each  group  but  only  some  well 
known  examples. 


364  GYNECOLOGIC  treat:ment 

Solutions  Used 

1.  Antiseptic  and  Astringent  Solutions. 

Protargol  Sol.  2%  to  10%. 
Argyrol  Sol.  20%  to  40 %o. 
Silver  Nitrate  Sol.  2%  to  10%. 
Bichloride  Sol.  1  to  500. 
Tinct.  Iodine. 

Copper  Sulphate  Sol.  10%. 
Adrenalin  Chloride  Sol.  1-1000. 
Liq.  Ferri  Subsnlphatis. 

Silver  Nitrate  solution  is  the  one  formerly  most  commonly  used  as  an 
antiseptic  application  to  the  genital  tract.  It  is  still  used  largely  and  with 
excellent  effect,  though  there  are  some  other  preparations  with  the  same 
effect  and  without  the  pain  on  application  and  the  discoloration  of  the  cloth- 
ing incident  to  the  use  of  silver  nitrate.  Silver  nitrate  is  the  pioneer  of  the 
silver  preparations.  It  is  used  in  the  treatment  of  vulvitis,  vaginitis,  erosion 
and  ulcer  about  cervix,  endocervicitis  and  endometritis.  The  strength  used, 
for  vulva  and  vagina  is  usually  2  per  cent  to  4  per  cent,  the  weaker  being 
used  at  first  when  the  parts  are  particularly  sensitive  and  the  stronger  later 
as  the  sensitiveness  becomes  less.  A  sensitive  inflamed  surface  or  an  abrasion 
or  ulcer  is  usually  much  diminished  in  sensitiveness  after  one  or  two  applica- 
tion, and  the  application  seems  also  to  stimulate  repair.  For  application  to  an 
eroded  area  or  an  ulcer  on  the  cervix,  4  per  cent  to  10  per  cent  is  used  to 
stimulate  repair. 

During  the  last  few  years  a  number  of  silver  preparations  have  been  put 
forward  as  superior  to  silver  nitrate  for  local  application.  Protargol  and 
argyrol  are  two  that  have  stood  the  test  of  extensive  use.  They  have  about 
the  same  or  perhaps  a  better  effect  than  silver  nitrate,  do  not  irritate  so  much 
and  do  not  form  permanent  stains  on  the  clothing  and  skin.  The  protargol  is 
used  in  the  same  strength  as  silver  nitrate.  The  argyrol  must  be  used  much 
stronger,  20  per  cent  to  40  per  cent.  It  is  the  least  irritating  of  the  silver 
preparations. 

The  bichloride  solution  is  strongly  antiseptic  and  mildly  astringent. 

Tincture  of  iodine  (either  the  ordinary  tincture  or  Churchill's  tincture) 
is  a  useful  antiseptic  and  stimulant  to  chronically  inflamed  areas  or  to  ero- 
sions or  ulcers.  It  was  formerly  much  used  as  a  counterirritant  application 
to  the  vaginal  vault  in  chronic  pelvic  inflammation,  but  more  effective  measures 
for  the  treatment  of  this  disease  are  now  available. 

The  copper  sulphate  solution  is  used  to  check  bleeding  and  to  stimulate 
healthy  cell  action  in  eroded  and  ulcerated  areas.  It  has  a  tendency  to  check 
bleeding  from  all  ulcers  except  those  due  to  beginning  malignant   disease. 


LOCAL    TREATMENT  365 

Consequently  it  is  helpful  in  the  differential  diagnosis  of  a  malignant  ulcer, 
as  explained  in  Chapter  ix. 

Liq.  Ferri  Subsulphatis  may  be  used  when  a  strong  hemostatic  applica- 
tion is  needed  for  a  bleeding  area. 

Adrenalin  affects  different  parts  of  the  mucosa  of  the  genital  tract  in  a 
different  manner.  It  seems,  in  some  cases  at  least,  to  have  no  effect  on  the 
mucosa  of  the  vagina,  but  a  pronounced  effect  on  that  of  the  uterus. 

2.  Cauterizing-  Solutions. 

Carbolic  Acid  95%. 
Iodized  Phenol. 
Nitric  Acid— C.  P. 

Carbolic  acid  is  employed  as  a  cauterant  application  to  unhealthy  ulcers 
on  the  cervix  or  vaginal  wall,  particularly  chancroidal  ulcers. 

Iodized  phenol  is  a  milder  cauterant,  more  superficial  and  less  irritating 
than  carbolic  acid  and  also  less  effective.  Nitric  acid  is  a  very  deep  and  pain- 
ful cauterant.  It  is  now  seldom  used,  as  carbolic  acid  is  effective  and  is  easier 
handled  and  causes  less  subsequent  disturbance. 

3.  Hygroscopic  Solutions. 

Glycerine. 

Boro-giycerine   (Boric  acid  50%). 

Carbol-giycerine    (Carbolic  acid  2%). 

Ichthyol-glycerine   (Ichthyol  10%) 

Protargol-glycerine    (Protargol  10%). 

Tannic-acid-giycerine  (Tannic  acid  10%). 
The  glycerine  preparations  are  used  for  the  hygroscopic  (water-extract- 
ing) effect  of  the  glycerine  and  also  for  the  special  effect  of  the  particular 
drug  incorporated  with  the  glycerine.  The  application  is  made  by  soaking 
one  end  of  a  tampon  in  the  desired  glycerine  preparation  and  then  introduc- 
ing it  through  the  speculum  into  the  upper  part  of  the  vagina,  the  medicated 
end  being  placed  against  the  cervix.  These  glycerine  tampons  are  used 
particularly  in  acute  and  chronic  inflammatory  conditions  in  the  pelvis.  They 
seem  to  assist  materially  in  diminishing  the  pain  and  soreness  and  they  cer- 
tainly exercise  a  decided  effect  on  the  adjacent  tissue  fluids,  for  the  patients 
often  remark  on  the  large  amount  of  water  which  comes  from  the  vagina 
when  using  these  glycerine  tampons. 

4.  Anesthetic  Solutions. 

Cocaine  Sol.  10%. 

Cocaine  Sol.  ^%   (for  hypodermic  injection). 
Eucaine  Sol. 
Chloretone  Sol. 
The  10  per  cent  cocaine  solution  is  used  for  local  application  to  painful 


366  GYNECOLOGIC   TREATMENT 

sores  or  abrasions,  to  dimmish  pain  during  examination  or  for  cauterization. 
The  Yi  per  cent  cocaine  solution  is  used  as  a  subcutaneous  or  submucous 
injection,  for  removing   small   growths   or  pieces   of   tissue   for   microscopic 
examination. 

POWDERS 

Powders  may  be  applied  by  means  of  the  powder  blower  or  they  may  be 
placed  on  a  cotton  or  gauze  tampon,  which  is  then  placed  in  the  upper  part  of 
the  vagina.  Powders  innumerable  have  been  used  for  this  purpose,  and  as 
a  rule  any  powder  that  is  a  good  antiseptic  application  for  wounds  is  good 
also  as  a  vaginal  application. 

Powders  are  used  principally  for  the  antiseptic  and  drying  effect  or  for 
an  anesthetic  effect. 

1.  Antiseptic  and  Drying. 

Pulv.  Boric  Acid. 

Xeroform  and  Boric  Acid   (1  to  4). 

Bismuth  Subnitrate. 

Bolus  Alba. 

Aristol. 

Pulverized  boric  acid  is  used  as  a  mild  antiseptic  and  drying  powder.  It 
is  bland  and  can  hardly  cause  irritation  even  with  children.  Xeroform  and 
boric  acid  (1  to  4)  is  preferable  when  a  stronger  antiseptic  powder  is  desired, 
in  fact,  it  is  the  powder  the  author  ordinarily  uses,  except  when  some  special 
astringent  or  anesthetic  effect  is  desired.  Xeroform  has  proved  a  very  satis- 
factory substitute  for  iodoform.  Its  action  in  stimulating  healthy  granula- 
tion, is  very  much  like  iodoform  and  it  has  practically  no  odor.  It  is  about  as 
effective  as  the  other  iodoform  substitutes  and  less  expensive. 

Bolus  Alba,  mixed  with  dried  yeast,  has  been  highly  recommended  as  a 
vaginal  application  in  cases  of  leucorrhea,  with  the  idea  that  the  yeast  fungi 
inhibit  the  growth  of  other  bacteria.  Gonorrheal  infections  are  probably 
favorably  influenced  by  this  powder. 

2.  Anesthetic  powders. 

Orthoform,  Xeroform  and  Boric  Acid  (1-1-4). 

Chloretone,  Xeroform  and  Boric  Acid  (1-1-4). 
Orthoform  is  a  powder  that  is  decidedly  anesthetic  and  for  that  reason 
is  advantageously  combined  with  powders  used  in  the  treatment  of  pain- 
ful affections  of  external  genitals,  vagina  and  cervix.  The  anesthetic  effect 
is,  of  course,  most  marked  when  the  poAvder  is  used  pure,  but,  like  cocaine,  it 
has  a  devitalizing  effect  on  poorly  nourished  tissues  and  may  cause  super- 
ficial sloughing  if  used  too  strong.  The  author  has  had  such  an  experience 
with  it  in  treating  superficial  abrasions  due  to  senile  pruritus  vulvae — the 
orthoform,  when  dusted  on  pure,  causing  the  abrasions  to  become  very  exten- 


TABLETS    AND    SUPPOSITORIES  867 

sive  instead  of  smaller.    A  similar  experience,  in  a  patient  past  the  menopause, 
was  related  to  him  by  one  of  his  colleag'ues. 

Chloretone  can  be  used  to  advantage  whenever  there  is  pruritus  or  a 
sense  of  soreness  in  the  vagina  or  about  the  external  genitals.  It  is  very 
satisfactory  as  a  dusting  powder  to  painful  ulcers,  chancroidal  and  other- 
wise. As  a  dusting  powder,  it  is  diluted  Avith  a  bland  poAvder  and  combined 
Avith  an  antiseptic  poAA^der  as  above  indicated. 

TABLETS 

Compressed  tablets  containing  antiseptic  or  astringent  or  anesthetic  drugs, 
are  put  up  for  vaginal  use.  They  may  be  introduced  to  the  upper  part  of 
the  vagina  by  the  patient,  either  folloAving  a  douche  or  without  a  douche, 
once  or  twice  daily  or  more  often  as  directed  by  the  physician. 

Tablets  of  various  formulae  for  vaginal  use  may  be  obtained.  They  are 
very  convenient  in  cases  Avhere  it  is  desirable  to  have  the  patient  use  some 
drug  betAveen  the  office  treatments  or  where  the  patient  can  not  come  to  the 
physician  or  be  seen  by  him  often  enough  for  regular  treatment.  Thdy  are 
not  as  effective,  however,  as  powder  applications  made  with  speculum  ex- 
posure of  the  affected  area  and  held  in  place  by  a  tampon,  as  in  office  treat- 
ment. In  prescribing  tablets  use  only  those  put  up  by  a  reliable  house,  so  that 
you  can  depend  on  the  stated  formula  and  knoAv  just  Avhat  you  are  using. 

The  effect  of  these  tablets,  dissolved  in  the  vagina,  as  of  other  vaginal 
medication,  is  of  course  only  local  (limited  to  superficial  effect  on  the  vagina 
and  cervix)  and  has  practically  no  influence  on  deep-seated  or  serious  vaginal 
or  uterine  or  periuterine  lesions.  Tablets  of  various  shapes  and  alleged 
formulae  and  called  by  fancy  names,  are  put  up  for  vaginal  use  by  patent 
medicine  venders  and  peddled  from  house  to  house  by  women  agents.  They 
are  put  forth  as  wonderful  discoveries  that  will  cure  all  "female  diseases," 
and  like  other  alleged  'Svonderful  discoA^eries"  they  deceive  many  a  poor 
Avoman  with  unfounded  hopes,  the  falseness  of  Avhich  in  serious  diseases  she 
often  discovers  only  AAdien  the  disease  is  past  cure.  It  is  another  case  of 
"blind  leading  the  blind"  or,  Avorse  still,  of  avarice  leading  the  blind. 

VAGINAL  SUPPOSITORIES  AND  CONES 

Vaginal  suppositories  furnish  another  method  of  applying  medicine  to 
the  vaginal  wall  and  cervix. 

In  vaginal  suppositories,  the  active  ingredient  is  incorporated  Avith  cocoa 
butter  or  other  suitable  material  Avhich  melts  in  the  vagina.  Vaginal  sup- 
positories are  used  principally  in  the  treatment  of  chronic  vaginitis  in  chil- 
dren, in  cases  in  Avhich  it  is  difficult  or  impracticable  to  employ  the  ordinary 
and  more  effective  methods  of  vaginal  treatment. 


GYNECOLOGIC    TREATMENT 


TAMPONS 


A  vaginal  tampon  is  simply  a  piece  of  absorbent  cotton  or  common  cot- 
ton or  wool  or  gauze,  of  the  desired  size  and  shape,  with  a  short  string  at- 
tached, so  that  the  tampon  may  be  removed  from  the  vagina  by  the  patient 
after  a  specified  time. 

One  way  to  make  a  cotton  tampon  is  to  take  a  rather  thick  piece  of  cot- 
ton (common  cotton  or  absorbent  cotton)  of  the  required  length  and  width 
and  thickness  and  tie  one  end  of  a  strong  string  firmly  about  the  middle. 
Fold  the  cotton  at  the  place  where  the  string  is  tied.  This  brings  the  free 
ends  together.  If  it  is  desired  to  use  a  solution,  the  free  ends  are  dipped  in 
it.  If  it  is  desired  to  use  powder,  the  free  ends  are  spread  out  so  as  to  make 
a  depression  in  which  the  powder  is  placed.  This  end  of  the  tampon  is  then 
caught  with  the  long  uterine  dressing  forceps  and  carried  up  to  the  cervix. 
Leave  the  string  long  enough  so  that  the  end  will  project  from  the  vagina, 
that  the  patient  may  easily  catch  it  and  remove  the  tampon  at  the  end  of 
twelve  to  twenty-four  hours  as  directed.  It  is  well  to  make  the  string  into  a 
loop  as  indicated  in  Fig.  426.  Tampons  made  of  surgical  wool  are  prefer- 
able when  the  principal  effect  desired  is  support,  as  they  are  much  more 
elastic  than  the  cotton  and  retain  their  elasticity  longer.  In  some  cases  the 
wool  proves  to  be  irritating  to  the  vaginal  walls.  To  prevent  this  and  yet 
secure  the  springiness  imparted  by  the  wool,  the  wool  tampon  may  be  cov- 
ered with  a  thin  layer  of  common  cotton. 

It  is  a  good  plan  to  keep  prepared,  ready  for  use,  a  number  of  tampons 
of  different  sizes.  They  may  be  prepared  during  leisure  and  they  are  then 
ready  when  needed,  and  thus  is  saved  considerable  time  and  inconvenience. 

When  the  vagina  is  tamponed  with  a  strip  of  gauze  or  with  cotton  balls 
without  strings,  it  is  referred  to  as  a  vaginal  tamponade.  The  author  has 
included  all  these  packings  under  the  general  term  "tampons." 

Tampons  of  cotton  or  wool  or  gauze  or  vaginal  packings  of  the  same,  are 
used  for  the  following  purposes: 

1.  To  secure  the  effect  of  drugs  incorporated  in  the  gauze  or  cotton  or 
held  in  place  by  them. 

2.  To  occlude  the  vagina  after  operations  in  its  upper  part. 

3.  To  stop  hemorrhage. 

4.  To  keep  inflamed  surfaces  separated. 

5.  To  support  the  pelvic  organs. 

6.  To  prevent  coitus. 

Tampons  are  much  used  for  holding  medicine  against  the  cervix  and 
vaginal  vault.  If  the  medicine  is  in  solution,  for  example,  one  of  the  glycerine 
preparations,  the  end  of  the  tampon  is  dipped  into  the  solution  and  then  ap- 
plied to  the  vaginal  vault  and  left  there,  to  be  removed  by  the  patient  after 
twelve  to  twenty-four  hours.    If  the  medicine  is  a  powder,  it  is  dusted  freely 


USE    OF    TAMPONS  369 

about  the  cervix  and  some  of  it  is  placed  on  the  end  of  the  tampon,  which 
is  introduced  as  before. 

When  used  to  occlude  the  vagina  after  an  operation,  the  gauze  or  cot- 
ton is  simply  a  surgical  dressing,  the  same  as  when  applied  to  an  external 


Fig.  426.  Preparation  of  Tampons,  a.  A  piece  of  cotton  of  the  required  size  with  a  strong  string 
tied  about  the  middle  and  also  a  loop  tied.  b.  The  same,  with  the  ends  folded  up  preparatory  to  re- 
ceiving powder  in  the  hollow  formed  there  or  to  being  dipped  into  an  application-solution.  _  c  Another 
satisfactory  way  of  making  a  tampon.  The  piece  of  cotton  is  folded  and  the  ends  are  tied  together 
and   the   string  looped,      d.    A   small   bowl    containing   tampons    ready    for   use. 


370 


GYNECOLOGIC    TREATMENT 


wound.  The  gauze  or  cotton  may  be  simply  sterile  or  it  may  be  impregnated 
with  some  antiseptic,  as  in  bichloride  gauze,  iodoform  gauze,  etc. 

When  gauze  or  cotton  is  used  to  check  hemorrhage  it  should  first  be 
wet  in  some  antiseptic  solution  and  then  squeezed  as  dry  as  possible  before 
being  packed  into  the  vagina.  Used  in  this  way  it  makes  a  much  more  effec- 
tive hemostatic  than  when  used  perfectly  dry. 

For  keeping  intlamed  surfaces  separated,  tampons  of  cotton  or  gauze- 
strips  are  used  in  the  various  forms  of  vaginitis. 

To  support  the  uterus  or  hold  it  in  position,  dry  gauze  or  cotton  or  wool 


Fig-.   427.     Tampon-Capsules.       a.     Large    size.      b.    Small    size.       c.     The    cap    removed,    showing    the 
tampon,     d.   A  tampon-capsule   prepared,   ready   for  introduction.      The   cap   was   removed   and   the   medicine 
poured    into    the    cap,    which    was    then    replaced, 
parent   cap. 


The    dark    ichthyol    mixture    shows    through    the    trans- 


is  used.  Wool  has  more  "spring"  in  it  than  cotton  or  gauze,  consequently  a 
wool  tampon  is  the  best  in  eases  where  only  support  is  required.  Sometimes 
the  wool  tampon  irritates  the  vagina,  in  which  case  it  may  be  covered  with 
a  thin  layer  of  cotton  as  before  mentioned.  When  cotton  is  used  for  sup- 
porting tampons,  ordinary  cotton  is  better  than  absorbent  cotton,  as  the 
latter  absorbs  fluids  rapidly  and  soon  loses  its  elasticity.  A  tampon  or  tam- 
ponade for  support  should  be  put  in  with  the  patient  in  the  Sims  posture  or 
in  the  knee-chest  posture. 


USE   OF   PESSARIES  871 

TAMPON-CAPSULES 

Ordinarily,  all  tampons  are  introduced  by  the  physician.  "When,  how- 
ever, it  is  advisable  that  tampons  be  applied  at  home  by  the  patient,  be- 
tween the  office  visits  or  in  conditions  in  which  the  patient  can  not  well 
come  to  the  office,  the  tampon-capsule  may  be  used.  The  tampon-capsule  is  a 
large  capsule  of  special  design  containing  a  plain  wool  tampon  with  a  string 
attached.  There  are  two  sizes  (Fig.  427).  They  come  in  boxes  of  a  dozen 
and  may  be  purchased  from  the  druggist  or  wholesale  drug-houses.  They 
are  convenient  for  use  immediately  after  the  hot  douche,  to  secure  hygro- 
scopic effect.  Just  before  use,  the  patient  removes  the  cap  from  the  capsule, 
pours  in  about  a  half  a  teaspoonful  of  any  desired  medicine  (usually  boro-gly- 
cerine  or  ichthyol-glycerine),  replaces  the  cap  and  introduces  the  capsule, 
medicated  end  first,  up  to  the  vaginal  vault.  Here  the  capsule  soon  melts, 
liberating  the  medicine  and  tampon,  and  the  latter  holds  the  former  in  place. 

PESSARIES 

Pessaries    are    appliances    introduced    into    the    vagina    for    the    pur- 
pose  of  holding  the  uterus  or  vaginal  wall  in  proper  position.     They   are 
made  of  hard  rubber  or  soft  rubber,  usually  the  former.     Those  made  of  soft 
rubber  are  generally  hollow  and  contain  air  or  flexible  wire.     Occasionally  a 
pessary  is  made  of  glass  or  block-tin  or  some  other  material. 
Pessaries  are  used  principally  for  the  following  affections : 
For  Backward  Displacement  of  the  Uterus. 
For  Prolapse  of  the  Uterus. 
For  Prolapse  of  the  Anterior  or  Posterior  Vaginal  Wall. 

For  Backward  Displacement  of  Uterus 

In  retrodisplacement  of  the  uterus  the  pessary  is  used  after  replace- 
ment, to  hold  the  uterus  in  proper  position.  Occasionally  a  pessary  is  used 
to  support  the  uterus  somewhat  when  complete  replacement  is  not  practicable. 

Varieties  Used 

Innumerable  forms  have  been  recommended,  and  to  attempt  to  men- 
tion all  of  them  would  be  a  waste  of  time.  The  following  four  varieties  are 
the  principal  ones  used  at  present  in  the  treatment  of  retrodisplacement,  and 
they  are  sufficient  in  practically  all  cases  in  which  a  pessary  is  the  prefer- 
able method  of  treatment. 

1.  Hodge  Pessary  (Fig.  428,  A).  This  pessary,  devised  by  Hugh  L. 
Hodge,  Professor  Diseases  of  Women  in  the  University  of  Pennsylvania  from 
1835  to  1863,  may  be  taken  as  the  type  of  the  hard  rubber  ring  pessaries.  It 
is  the  original  model  from  which  nearly  all  other  pessaries  of  that  character 


872 


GYNECOLOGIC    TREATMENT 


descended.    It  is  still  much  used  and,  as  explained  later,  is  the  most  suitable 
one  for  certain  conditions. 

2.  Albert  Smith  Pessary  (Fig.  428,  B).  Albert  H.  Smith  modified  the 
Hodge  Pessary  in  two  important  particulars.  He  narrowed  the  anterior  end 
so  that  it  fits  well  up  into  the  narrow  portion  of  the  pubic  arch,  the  point 
projecting  slightly  into  the  arch.  This  tends  to  keep  the  pessary  from  turning 
or  slipping  about  in  the  vagina  and  at  the  same  time  causes  the  anterior  part 
of  the  pessary  to  lie  higher— so  that  it  is  out  of  the  way  and  does  not  inter- 
fere with  coitus  or  with  the  introduction  of  a  douche  nozzle.  .  His  other 
modification  was  a  lengthening  of  the  posterior  arm  of  the  pessary.  This 
pushes  the  posterior  vaginal  fornix  further  upward  and  backward,  thus  in- 
creasing the  ability  of  the  pessary  to  hold  the  cervix  uteri  well  back  in  the 
pelvis. 

3.  Thomas  Pessary  (Fig.  428,  C),  sometimes  called  the  Smith-Thomas 
pessary.     T.  Gaillard  Thomas  modified  the  Smith  pessary   (which  was  itself 


A  B  C 

Fig.  428.     A.    The   Hodge    Pessary.      B.    The   Albert    Smith   Pessary.      C.    The   Thomas   Pessary. 

a  modification  of  the  Hodge  pessary)  by  thickening  the  posterior  end  into 
a  bulbous  enlargement.  This  distributes  the  pressure  over  a  larger  surface 
of  the  posterior  fornix,  and  in  that  way  tends  to  prevent  pressure  injury  of 
the  vaginal  vault  at  that  point. 

4.  Inflated  Ring-  Pessary,  to  be  described  later. 


Action  of  the  Pessary 

The  action  of  the  Hodge  pessary  and  its  modifications,  as  ordinarily  used 
in  a  case  of  retrodisplacement,  is  to  hold  the  cervix  back  in  the  hollow  of 
the  sacrum.  As  long  as  the  cervix  is  held  well  back  in  the  pelvis,  the 
fundus  uteri  will  stay  forward  where  it  belongs.  The  pessary  holds  the 
cervix  uteri  back  in  place  by  holding  back  the  posterior  vaginal  vault  (to 
which  the  cervix  is  closely  attached)  and  also  by  pushing  upward  and  back- 
ward on  the  sacro-uterine  ligaments,  thus  putting  them  on  the  stretch.     To 


USE   OF   PESSARIES 


373 


accomplish  this,  the  anterior  portion  of  the  pessary  must  have  a  rather  firm 
support,  which  it  gets  from  the  pubic  arch  (with  intervening  soft  tissues) 
and  the  pelvic  floor. 

The  action  of  the  pessary,  with  its  many  curves,  seems  to  be  a  veritable 
puzzle  to  many  students  and  to  not  a  few  practitioners,  yeMit  is  clear  enough 


when  properly  approached  and  studied.  In  order  to  maKe  the  matter  clear 
to  the  author's  classes  in  a  short  explanation,  he  is  accustomed  to  approach 
the  subject  synthetically  so  to  speak,  i.e.,  to  gradually  build  up  in  mind  such 
a  pessary.  We  know  that  after  a  movable  retrodisplaced  uterus  has  been 
replaced,  if  we  keep  the  cervix  well  back  in  the  pelvic  cavity,  that  is,  a  cer- 
tain, distance  from  the  vaginal  outlet,  the  fundus  will  stay  forward  (Fig.  429). 
Suppose  then  that  we  introduce  a  straight  stick  that  reaches  from  the  pubic 


Fig.  429.  The  Pessary  in  Place.  The  action  of  the  pessary  is  to  hold  the  posterior  vaginal 
fornix,  and  with  it  the  attached  cervix,  well  backward  and  upward  in  the  pelvis.  (Skene — Diseases  of 
Women.) 


arch  to  the  posterior  vaginal  vault.  Now  as  long  as  the  anterior  end  of  the 
stick  is  supported  by  the  pubic  arch,  neither  the  posterior  vaginal  fornix  nor 
the  cervix,  which  is  closely  attached  to  it,  can  approach  the  vaginal  outlet. 
The  cervix  can  move  up  and  down  through  a  small  arc,  but  it  cannot  come 
any  nearer  the  vaginal  outlet  and  consequently  as  the  cervix  is  held  Avell 
back  in  the  pelvis  the  fundus  uteri  stays  forward. 

This  is  practically  the  action  of  the  pessary.  It  takes  its  fixed  point  of 
support  from  the  pubic  arch  (the  soft  tissues  intervening),  being  held  up 
against  the  narrow  part  of  the  arch  by  the  pelvic  floor.  As  long  as  the  an- 
terior end  of  the  pessary  is  properly  supported  (held  stationary)  the  posterior 
end  holds  the  posterior  vaginal  vault  and  the  attached  cervix  well  back  in 


374  GYNECOLOGIC    TREATMENT 

the  pelvis.  The  ring  shape  of  the  pessary  and  the  various  curves  are  simply 
to  adjust  it  comfortably  to  the  adjacent  structures.  The  open  ring  permits 
the  pessary  to  lie  up  well  out  of  the  way  in  the  lateral  angles  of  the  vaginal 
canal  and  also  permits  the  cervix  to  project  through  the  pessary  and  the 
uterine  secretions  to  flow  outward  without  hindrance.  The  marked  upward 
bend  of  the  posterior  portion  of  the  pessary  increases  its  ability  to  push  the 
posterior  vaginal  fornix  upward  and  backward  and  put  the  sacro-uterine 
ligaments  on  the  stretch.  The  long  upward  curve  of  the  front  part  of 
the  pessary  with  the  narrow  anterior  end  permits  the  anterior  end  to  lie 
up  out  of  the  way  in  the  narrow  part  of  the  arch,  and  also  furnishes  a  slope 
against  which  the  perineum  and  front  part  of  the  pelvic  floor  acts  advantage- 
ously, helping  to  support  the  pessary  in  both  an  upward  and  backward  direc- 
tion and  thus  taking  some  of  the  pressure  off  the  extreme  anterior  end.  If 
all  the  pressure  on  the  pessary  were  transmitted  to  the  very  end,  it  would 
cause  pain  by  pinching  the  soft  tissues  between  the  pessary  and  the  bony 
arch.  With  the  long  steep  upward  curA^e,  however,  a  large  part  of  the  down- 
ward and  forward  pressure  is  borne  by  the  pelvic  floor.  The  little  trans- 
verse notch  or  downward,  dip  at  the  anterior  end  of  the  pessary  is  to  prevent 
pressure  on  the  urethra  as  the  pessary  lies  well  up  in  the  angle  of  the  pubic 
arch. 

The  two  principal  factors  in  the  support  of  such  a  pessary  are  the  pubic 
arch  and  the  pelvic  floor.  As  to  just  which  furnishes  the  most  support,  it  is 
hard  to  say — probably  there  is  much  variation  in  different  cases,  depending 
on  the  conformation  of  the  parts  and  the  shape  of  the  pessary. 

AVhen  the  pelvic  floor  is  severely  torn  it  permits  the  pessary  to  sink 
lower  in  the  pelvis.  The  anterior  narrow  end  lies  at  a  wide  part  of  the  arch, 
a  part  too  Avide  to  furnish  support  for  it  and  it  slips  outside  a  short  distance. 
This  permits  the  cer^dx  to  come  forAvard  and  then  the  fundus  goes  backAvard. 
NoAV  in  such  a  case,  if  Ave  use  a  pessary  AAdth  a  Avider  anterior  end  (e.g.,  the 
regular  Hodge  pessary)  it,  being  AAader,  impinges  on  the  sides  of  the  arch 
and  holds  the  cervix  back  AA^here  it  belongs.  In  very  severe  laceration,  the 
marked  relaxation  of  the  pehdc  floor  alloAvs  the  pessary  to  come  so  Ioaa^ — to 
such  a  very  Avide  part  of  the  arch — that  not  even  the  Hodge  pessary  Avill  stay 
in.  In  such  a  case  some  temporary  relief  may  be  given  by  other  styles  of  pes- 
sary to  be  mentioned  later. 

Selection  of  Pessary 

The  selection  of  the  pessary  best  adapted  to  a  particular  case  concerns 
the  style,  size  and  special  modiflcations. 

As  to  style  or  form,  in  retrodisplacement  the  author  prefers  the  Thomas 
pessary  in  all  but  exceptional  cases.     The  adA'antages  of  this  form  are : 

a.  XarroAv  anterior  end  that  lies  Avell  up  out  of  the  Avay.  There  is  little 
or  no  interference  Avith  coitus  or  Avith  the  introduction  of  the  douche  nozzle. 


USE    OF   PESSARIES  375 

b.  Long  steep  anterior  slope  on  Avhich  the  pelvic  floor  can  act  to  advan- 
tage in  assisting  in  the  support  of  the  pessary. 

c.  Long  posterior  arm,  which  tends  to  keep  the  posterior  vaginal  fornix 
■well  up. 

d.  Thick  posterior  end,  Vvdiich  distributes  the  pressure  over  a  wide  sur- 
face of  the  posterior  vaginal  fornix  and  thus  prevents  injurious  pressure  or 
ulceration  at  any  point. 

The  exceptional  cases  in  which  the  Thomas  pessary  is  not  satisfactory, 
are  as  follows : 

1.  AVhere  there  is  a  severe  laceration  of  the  iDelvic  floor.  Li  these  cases 
a  pessary  with  a  wider  anterior  end  is  reciuired,  as  previously  explained.  Here 
the  regular  Hodge  pessary  is  usually  the  preferable  one.  In  lacerations  of 
extreme  severity,  where  the  parts  are  so  relaxed  that  neither  the  Hodge  nor 
Smith  nor  Thomas  pessary  will  stay  in,  the  inflated  ring  pessary  or  one  of 
the  other  forms  mentioned  under  prolapse  may  give  some  temporary  relief. 
For  permanent  relief  in  such  a  case  operative  measures  are  required. 

2.  AVhere  the  posterior  vaginal  fornix  is  too  small  or  shallow  to  accom- 
modate the  large  bulbous  end.  In  such  a  ease  the  Smith  or  the  Hodge  pes- 
sary may  be  used.  In  each  of  these  the  posterior  bar  is  of  small  diameter 
and  will  fit  into  a  small  posterior  fornix.  If  the  pelvic  floor  is  not  too 
badly  torn  the  Smith  pessary  is  the  preferable  one  of  the  two,  as  it  has  the 
narrow  anterior  end  and  the  long  posterior  arm. 

3.  AVhen  there  are  painful  inflammatory  lesions  about  the  uterus  or  a 
prolapsed  and  tender  ovary.  In  some  of  these  cases  the  pessary  may  be  worn 
without  discomfort  after  the  parts  have  been  held  in  place  by  tampons  for  a 
few  days.  In  others,  the  tenderness  persists  and  any  form  of  pessary  which 
pushes  well  up  behind  the  cervix  causes  pain  and  hence  can  not  be  worn. 
In  such  cases  the  inflated  ring  pessary  sometimes  gives  considerable  relief 
1)y  diminishing  the  dragging  of  the  heavy  uterus  on  the  inflamed  adnexa  and 
broad  ligaments.  As  a  rule,  however,  in  such  cases  time  spent  with  pes- 
saries is  time  wasted,  as  far  as  any  permanent  relief  is  concerned. 

As  to  the  size  of  pessary  to  be  selected,  the  approximate  length  may  be 
determined  by  measuring  with  the  examining  fingers  the  distance  from  the 
posterior  vaginal  vault  (pushed  well  up)  to  the  pubic  arch.  The  length  of 
the  pessary  should  be  a  trifle  less  than  this.  The  width  of  pessary  which 
the  vagina  will  accommodate  may  be  determined  approximately  by  the  ap- 
parent roominess  of  the  vagina  as  felt  on  vaginal  palpation.  A  special  maneu- 
ver for  this  purpose  is  to  introduce  the  two  examining  fingers  to  the  upper 
part  of  the  vagina,  separate  them  laterally  as  far  as  the  vaginal  walls  will 
permit  and  then  withdraw  them  in  the  antero-posterior  diameter  (the  largest 
diameter  of  the  vaginal  outlet),  retaining  them  as  nearly  as  possible  in  the 
original  position. 

However,  the  size  of  pessary  that  will  keep  the  uterus  in  position  with 
the  least  discomfort  can  be  determined  certainly  only  by  trial,  and  several 


376  GYNECOLOGIC    TREATMENT 

pessaries  may  have  to  be  worn  for  a  short  time  before  the  most  satisfac- 
tory one  for  that  particular  case  is  settled  upon.  A  pessary  that  is  too  small 
fails  to  hold  the  uterus  in  position  and  tends  to  slip  out.  A  pessary  that 
is  too  large  causes  pain.  It  is  better  to  give  too  small  than  too  large  a  pes- 
sary, as  the  latter  may  cause  severe  pain  after  it  has  been  in  place  a  day  or 
two,  and  if  the  patient  is  a  long  way  from  the  physician  and  can  not  suc- 
ceed in  removing  the  pessary  herself,  she  may  experience  much  suffering. 

The  special  modifications  refer  to  slight  changes  in  shape  from  the  regu- 
lar form,  occasionally  required  to  make  the  pessary  more  comfortable  or 
more  satisfactory  in  retaining  the  uterus  in  position. 

1,  General  narrowing  of  the  pessary.  The  pessaries  as  purchased  main- 
tain a  ratio  between  the  width  and  the  length  (the  longer  the  pessary  the 
wider  it  is).  As  a  rule  this  is  desirable.  In  some  cases,  however,  the  vaginal 
opening  is  too  small  to  admit  a  pessary  of  sufficient  length.  To  overcome 
this  difficulty  drop  the  pessary  in  hot  water  for  a  moment,  until  it  becomes 
slightly  pliable,  then  remove  it  with  a  forceps,  grasp  it  with  a  towel  and 
squeeze  it  so  as  to  narrow  it  laterally  to  the  required  extent,  and  hold  it 
thus  until  it  cools.  The  cooling  may  be  hastened  by  holding  it  in  cold  water. 
Do  not  keep  it  very  long  in  the  hot  water  or  it  will  become  so  pliable  that  it 
flattens  into  a  simple  ring,  and  all  the  characteristic  curves  are  lost. 

2.  Local  Bending.  Occasionally  it  is  desired  to  bend  a  hard  rubber  pes- 
sary at  some  particular  point,  so  as  to  change  an  ordinary  curve  to  an 
unusual  one  or  to  change  one  form  of  pessary  to  resemble  another  form, 
which  is  needed  but  is  not  on  hand.  To  make  these  local  bendings,  coat  that 
part  of  the  pessary  to  be  bent  liberally  with  vaseline  or  other  ointment  and 
hold  it  high  above  the  flame  of  an  alcohol  lamp  or  Bunsen  burner.  Hold  it 
close  enough  to  the  flame  to  heat  the  pessary  well  at  the  exact  area  it  is 
desired  to  bend  but  not  close  enough  to  burn  off  the  ointment.  In  a  few 
moments  the  pessary  is  softened  sufficiently  to  permit  bending.  If  the 
pessary  is  brought  too  close  to  the  flame,  it  is  burned  and  the  smooth  surface 
roughened. 

In  1859,  J.  Marion  Sims  introduced  the  block-tin  modification  of  the 
Hodge  pessary,  the  advantage  of  this  material  being  that  it  is  sufficiently 
pliable  to  be  moulded  to  any  shape  and  yet  firm  enough  to  hold  the  shape 
given  it.  The  block-tin  pessary  was  the  favorite  with  T.  A.  Emmet  and 
was  highly  recommended  by  him,  but  it  is  not  so  frequently  used  at  the 
present  time.     Ordinarily  the  hard  rubber  pessary  is  preferable. 

Pessary  Used  Only  After  Replacement 

The  pessary  is  ordinarily  not  used  until  the  uterus  has  been  brought 
forward.  The  pessary  is  not,  as  many  suppose,  used  to  push  the  fundus  uteri 
forward,  neither  is  it  used  to  prop  the  fundus  forward.  The  pessary  has 
nothing  to  do  directly  with  this  part  of  the  uterus.     All  the  pessary  does  is 


USE   OF   PESSARIES 


381 


When  the  pessary  is  found  satisfactory  at  the  second  and  third  visits,  it 
is  to  be  assumed  that  it  will  prove  satisfactory  right  along,  and  as  long  as 
the  patient  feels  well  she  need  not  return,  except  every  month  or  six  weeks 
as  above  indicated.  This  return  at  regular  intervals  of  a  few  weeks  is  im- 
portant in  every  case  (though,  exceptionally,  the  intervals  may  be  longer) 
for  three  reasons — (a)  because  the  pessary  is  liable  to  accumulate  concretions 
that  may  prove  irritating,  (b)  because  long-continued  pressure  may  produce 
ulceration  at  some  point  in  the  posterior  vaginal  fornix  and  (e)  because  it  is 


'  ""^3c%^:^ 


Fig.   435.     Introducing    the    Pessary.       The    posterior    end    depressed    and    being    pushed    past    the    cervix. 
The   pessary   is   shown   in   place   in    Fig.    429. 


important  to  know  whether  the  pessary  is  doing  the  work  it  is  used  for,  and 
if  everything  is  going  as  it  should.  Injurious  pressure  on  the  Avail  is  indi- 
cated by  a  distinct  groove  or  ridge  with  infiltration  in  the  affected  area. 
When  such  is  present,  the  pessary  should  be  left  out  for  a  few  weeks  or  a  dif- 
ferent form  used.  If  necessary  to  leave  the  pessary  out  for  a  time  and 
trouble  is  experienced  from  the  uterus  returning  to  its  malposition,  packing 
in  the  knee-chest  posture  or  in  the  Sims  posture  may  be  employed  during 


382  GTXECOLOGIC    TREATMENT 

this  interval.  In  many  eases,  however,  a  resort  to  the  knee-chest  posture 
night  and  morning  is  all  that  is  necessary. 

Douches.  The  patient  wearing  a  pessary  should  take  a  vaginal  douche 
every  day  or  every  few  days.  If  the  discharge  is  very  free  it  may  be  advis- 
able to  take  two  or  three  douches  daily.  If  there  is  practically  no  discharge 
two  douches  weekly  may  be  sufficient.  Ordinarily  the  patient  is  directed  to 
take  a  douche  once  daily  or  every  other  day.  The  kind  of  douche  to  be 
taken  varies  with  the  conditions  present — a  large  hot  douche  or  an  astringent 
douche  when  the  indications  previously  given  for  them  are  present.  AYhen 
there  are  no  special  indications,  prescribe  the  bichloride  douche  or  the  alumi- 
num acetate  douche. 

Knee-chest  Posture.  The  knee-chest  posture  (Fig.  445)  taken  by  the 
patient  night  and  morning,  is  very  useful  in  those  cases  in  which  the  uterus 
tends  to  return  to  its  old  position  or  in  which  the  patient  complains  of  down- 
ward pressure  in  the  pelvis.  It  causes  the  patient  some  inconvenience  and  is 
not  necessary  when  the  pessary  holds  the  uterus  well  up  and  entirely  relieves 
the  symptoms.  But  in  many  cases  of  damaged  pelvic  floor,  its  use  along  with 
the  pessary  is  very  advantageous. 

The  activity  of  the  patient  need  not  be  curtailed  on  account  of  the  pes- 
sary. The  pessary  is  meant  to  hold  the  uterus  in  proper  position  and  restore 
the  patient  to  comparative  health,  so  that  she  can  pursue  her  usual  activities 
without  disturbance.  If  the  patient  can  not  pursue  her  usual  activities,  after 
the  pessary  has  been  worn  a  month  or  two,  the  pessary  has  failed  of  its  pur- 
pose, and  some  more  effective  method  of  treatment  is  indicated. 

As  to  coitus,  the  fact  that  a  pessary  is  being  worn  is  no  bar  to  sexual  inter- 
course. With  the  Thomas  pessary  and  the  Smith  pessary,  the  anterior  end 
lies  so  high  in  that  it  interferes  but  little,  if  at  all.  Even  with  the  Hodge 
pessary,  coitus  may,  in  some  cases,  be  accomplished  with  but  little  inconveni- 
ence. Coitus,  however,  causes  marked  pelvic  congestion  and  this  increases 
the  liability  of  discomfort  resulting  from  the  pressure  of  the  pessary.  Conse- 
quently for  the  first  few  weeks,  while  the  pessary  is  on  trial  so  to  speak,  coitus 
had  best  be  discontinued.  Later,  after  the  uterus  has  been  sometime  in  its 
proper  position  and  the  pelvic  structures  are  adjusted  to  the  pessary,  no  re- 
striction in  this  direction  is  necessary  ordinarily. 

In  some  cases,  the  replacement  of  the  uterus  and  wearing  of  the  pessary 
is  carried  out  principally  to  increase  the  chance  of  pregnancy,  and  in  such 
cases  coitus  is  permissible  from  the  first.  It  is  well  to  mention  this  fact  to  the 
patient  or  her  husband,  as  otherwise  it  may  be  thought  that  coitus  is  not  pos- 
sible while  the  pessary  is  in  place. 

If  pregnancy  should  develop,  the  pessary  should  be  worn  just  the  same 
until  the  uterus  has  become  large  enough  to  prevent  its  sinking  back  into  the 
pelvis.  The  douche  should  then  be  taken  only  warm — not  hot,  for  a  hot  douche 
mav  excite  uterine  contractions  and  lead  to  miscarriage.    Usually  along  in  the 


USE   OF   PESSARIES  383 

third  or  fourth  month  the  pessary  is  taken  out,  as  it  is  of  no  further  use  and 
if  left  in  longer  it  might  cause  irritation  and  disturbance. 

Occasionally  a  pessary  excites  pain  shortly  after  pregnancy  takes  place. 
If  so,  it  should  be  removed,  the  patient  being  directed  to  take  the  knee-chest 
posture  two  or  three  times  daily,  to  keep  the  fundus  uteri  forward.  Tampons 
or  tamponade  of  the  vagina  to  keep  the  uterus  forward  is  not  advisable  in 
these  cases,  as  it  might  lead  to  miscarriage. 

When  to  Discard  the  Pessary 

The  time  at  which  the  pessary  may  be  discarded  varies  much  in  differ- 
ent cases,  and  in  each  case  is  more  or  less  a  matter  of  trial.  A  very  good  rule 
is  to  leave  out  the  pessary  after  the  uterus  has  remained  in  position  continu- 
ously for  three  or  four  months.  Direct  the  patient  to  return  in  two  or 
three  days.  If  the  uterus  has  returned  to  its  old  backward  position,  replace 
it  and  use  the  pessary  again  for  several  months. 

If  the  uterus  maintains  its  forward  position  Avith  the  pessary  out,  direct 
the  patient  to  return  again  in  two  wrecks.  If  then  the  uterus  is  in  proper  posi- 
tion and  the  patient  feeling  well  she  may  be  discharged,  being  directed  to  re- 
turn if  symptoms  should  at  any  time  reappear. 

In  some  cases  the  pessary  may  be  permanently  discontinued  in  three  or 
four  months,  but  in  more  cases  it  must  be  worn  for  six  months  or  a  year,  while 
in  certain  cases,  it  must  be  worn  a  still  longer  time  or  even  indefinitely. 

If  after  the  pessary  is  removed,  the  uterus  shows  a  tendency  to  go  back- 
ward, it  is  well  to  have  the  patient  take  the  knee-chest  posture  occasionally  for 
some  months. 

The  Inflated  Ring  Pessary 

The  action  of  the  inflated  ring  pessary  (Fig.  436,  B)  is  principally  to  raise 
the  uterus  and  adjacent  tissues  somewhat  and  to  support  them.  It  has  no 
particular  action  in  holding  the  cervix  well  back  in  the  pelvis  nor  in  main- 
taining the  uterus  in  a  proper  forward  position.  Consequently  the  field  of 
usefulness  of  this  particular  form  of  pessary  is  in  those  cases  in  which  the 
uterus  can  not  be  got  into  the  forward  position  or  can  not  be  maintained  there. 
The  simple  supporting  of  the  uterus,  thus  overcoming  the  slight  prolapse 
which  is  present  in  most  cases  of  retrodisplacement,  often  gives  the  patient 
much  relief,  though  the  retrodisplacement  has  not  been  corrected. 

On  the  other  hand,  such  a  pessary  is  sometimes  used  by  the  physician  or 
by  the  patient  on  her  own  responsibility  (this  form  of  pessary  being  frequently 
advertised  to  the  laity),  in  cases  where  complete  replacement  could  be  easily 
accomplished.  In  such  a  case,  complete  replacement  with  the  subsequent  use 
of  the  Thomas  or  Hodge  pessary  would  tend  to  effect  a  cure,  while  the  effect 
of  the  inflated  ring  pessary  is  imperfect  and  only  temporary. 

In  the  cases  in  which  the  inflated  ring  pessary  is  useful,  some  radical 


384  GYNECOLOGIC    TREATMENT 

measures  are  usually  preferable  and  the  pessary  is  simply  a  temporary  expedi- 
ent to  make  the  patient  more  comfortable  while  she  is  getting  ready  for  opera- 
tion. Some  patients,  however,  prefer  to  wear  the  pessary  indefinitely,  even 
though  it  affords  only  partial  relief,  rather  than  submit  to  any  operative 
measure. 

This  pessary  requires  a  douche  every  day  and  should  be  removed  and 
cleansed  at  least  every  Aveek.  It  requires  more  care  to  prevent  incrustation 
and  irritation.  The  patient  can  usually  remove  and  reintroduce  the  pessary 
satisfactorily  herself  after  a  little  practice.  Just  before  introducing  it,  the 
patient  should  take  the  knee-chest  posture  for  a  few  minutes.  Then  lying 
on  her  back  or  side  she  introduces  the  pessary,  which  has  been  previously 
cleansed  and  lubricated.  When  coitus  is  desired,  the  pessary  may  be  taken 
out  in  the  evening  and  left  out  until  morning.  If  desired  a  loop  of  strong 
string  may  be  attached  to  the  pessary  to  facilitate  its  removal.  If  the  pessary 
becomes  deflated,  it  may  be  reinflated  with  a  hypodermic  syringe,  the  needle 
being  introduced  through  the  thick  spot  designed  for  that  purpose. 


A  B  c 

Fig.  436.     A.   Flexible  Ring  Pessary.     B.  Inflated  Ring  Pessary.     C.   Hard  Rubber  Disk  Pessary. 

A  pessary  of  about  this  form  is  made  of  hard  rubber  (Fig.  436,  C)  and  is 
used  in  the  same  way.  It  does  not  become  deflated  and  is  less  likely  to  ac- 
cumulate incrustation  and  irritate  the  vaginal  wall.  It  is  unyielding,  however, 
and  for  that  reason  is  more  likely  to  produce  painful  pressure  at  some  point. 
Also  a  smaller  size  must  be  used,  for  this  pessary  can  not  be  compressed,  as  the 
inflated  rubber  pessary  can,  to  pass  the  vaginal  oriflce. 

5.  Flexible  Ring  Pessary.  The  flexible-rubber  ring  (Fig.  436,  A)  is  some- 
times preferable  to  the  inflated  ring,  particularly  in  cases  where  there  is  very 
free  discharge.  The  opening  being  larger,  the  free  discharge  escapes  easier 
and  consequently  there  is  less  retention  and  irritation. 

Pessaries  for  Prolapse  of  Uterus 

The  treatment  for  prolapse  is  to  raise  the  uterus  and  maintain  the  fundus 
in  a  forward  position.  The  pessary  that  accomplishes  this  in  a  case  of  retro- 
displacement  is  likewise  beneficial  in  a  case  in  which  the  prolapse  is  the  prin- 
cipal feature.     Consequently,  in  the  milder  grades  of  prolapse,  a  Thomas  or 


USE    OF   PESSARIES 


385 


Smith  or  Hodge  pessary  may  be  all  that  is  necessary  to  maintain  the  uterus 
in  its  proper  position. 

In  many  cases  of  prolapse,  however,  more  so  than  in  retroclisplacement, 
the  pelvic  floor  has  been  torn  so  much  that  this  form  of  pessary  will  not  stay, 
in  satisfactorily.  In  such  a  case,  a  large  inflated  rubber  ring  pessary  may  be 
introduced  and  then  turned  so  it  will  not  slip  out.  This  does  not  hold  the 
cervix  back  in  the  pelvis  and  the  fundus  forward,  but  it  does  plug  the  vaginal 


Fig.  437.  The  Menge  Pessary.  A.  The  i.<rs:?aiy  wiui  the  stem  in  place.  B.  The  pessary  with 
the  stem  detached  from  the  ring  portion  of  the  pessary,  preparatory  to  introduction  of  the  latter. 
After  the  ring  portion  has  been  introduced,  the  stem  is  fastened  in  place  as  shown  in  C.  *^he 
stem  lies  in  the  vaginal  canal,  and  keeps  the  ring  from  turning  into  any  position  that  will  allow  it 
to    slip    out. 


opening  so  the  redundant  vaginal  wall  and  the  uterus  can  not  prolapse  to  the 
former  extent.  If  the  pessary  tends  to  protrude,  a  pad  over  the  genitals,  with 
a  firm  T-bandage,  may  keep  it  in  place  comfortably. 

6.  Meng'e  Pessary.  A  large  thick  rubber  ring,  turned  crosswise  in  the 
vaginal  canal  will  plug  the  opening  effectually  for  a  time.  But  when  the 
patient  walks  around  for  a  few  hours,  the  ring  shifts  about  until  the  edge  is 


386 


GYNECOLOGIC    TREATMENT 


Fig.  438.  The  Gehrung  Pessary.  A.  The  pessary  as  viewed  from  above.  B.  The  pessary  as 
viewed  from  the  side.  C.  The  pessary  in  place,  showing  the  action  of  the  upper  arch  in  holding  up 
the  uterus  and  base  of  the  bladder.  D.  Showing  how  the  heel  on  each  side  indents  the  tissues  some 
distance  from  the  vaginal  opening,  instead  of  pressing  into  the  opening  like  a  wedge,  as  do  other 
pessaries. 


Fig.   439.     Introducing  the   Gehrung  pessary.      A.    Showing  how   the   pessary   is   held.      B.    First   step   in   the 
introduction — see    directions    for    introduction. 


USE   OF   PESSARIES  387 

turned  toward  the  relaxed  vaginal  opening  and  then  it  slips  out.  The  Menge 
pessary  (Fig.  437,  A)  consists  of  such  a  hard  rubber  ring,  with  a  stem  which 
prevents  the  pessary  from  turning.     The  stem  is  detachable  as  shown  in  Fig. 

437,  B.  The  thick  ring  is  introduced  the  same  as  any  large  ring  pessary  and 
turned  across  the  vaginal  canal,  with  the  hole  in  the  cross-bar  directed  toward 
the  vaginal  opening.  The  stem  is  then  fastened  in  place.  The  stem  lying  in 
the  vaginal  canal  as  shown  in  Fig.  437,  C,  prevents  the  ring  from  turning,  and 
hence  the  vaginal  opening  is  persistently  blocked  and  the  prolapse  prevented. 

This  pessary  has  proved  very  useful  in  severe  cases,  where  operation  was 
inadvisable  or  was  refused,  or  where  temporary  relief  was  required  while  the 
patient  was  waiting  for  operation. 

7.  Gehrung  Pessary.  The  Gehrung  pessary  consists  of  two  light  arches 
of  horseshoe  shape  joined  at  their  heels  (Fig.  438,  A  and  B).  When  in  position 
(Fig.  438,  C)  the  lower  arch  or  horseshoe  secures  support  on  the  remnants  of 
the  pelvic  floor  at  the  sides  of  the  vaginal  opening  (Fig.  438,  D).  This  in  turn 
supports  the  upper  arch,  which  holds  up  the  bladder  and  uterus,  as  shown  in 
the  illustration.  This  is  the  most  satisfactory  pessary  that  the  author  has 
found  so  far  for  the  treatment  of  inoperable  prolapse  or  cystocele.  The  secret 
of  its  effectiveness  in  the  severe  cases  Avith  almost  no  pelvic  floor,  lies  in  the 
method  of  obtaining  support  from  the  remnant  of  the  pelvic  floor.  With  the 
ordinary  pessary  the  lower  supporting  portion  presses  against  the  vaginal 
opening  in  the  form  of  a  Avedge,  which  tends  to  stretch  the  opening  more  and 
more — until  finally  the  pessary  slips  out.  Owing  to  the  wedge  shape  of  the 
presenting  part  of  the  pessary,  there  is  a  sidcAvise  pressure  which  tends  to  push 
aside  the  shelf  of  pelvic  floor  upon  Avhich  the  pessary  must  depend  for  supi^ort. 
The  result  is  that  the  small  shelf  of  pelvic  floor  on  each  side  is  gradually  flat- 
tened out  against  the  pelvic  Avail,  permitting  the  pessary  to  slip  out.  Even  the 
Menge  pessary  has  this  Avedge  action  to  some  extent. 

With  the  Gehrung  pessary,  on  the  other  hand,  tlie  supporting  part  of  the 
arch,  on  each  side  presses  into  the  shelf  of  tissue  from  above  and  some  dis- 
tance from  its  margin,  as  indicated  in  Fig.  438,  D.  This  pressure  into  the 
superior  surface  of  the  supporting  shelf  causes  a  depression  on  each  side  (Fig. 

438,  D)  in  which  the  pessary  becomes  "set"  so  that  it  does  not  slip  around. 
The  more  the  pressure  the  more  firmly  it  becomes  set,  after  it  is- well  placed. 
Acting  in  this  Avay  it  does  not  tend  to  stretch  the  A^aginal  opening  and  slip 
out,  as  do  the  pessaries  AAdth  Avedge  action.  In  fact,  after  this  pessary  has 
been  worn  for  a  Avhile  and  is  w^ell  set  in  each  side,  a  smaller  one  Avill  often 
ansAver  the  purpose.  The  parts  seem  to  contract  someAvhat,  AA^hen  relieved 
for  a  time  from  the  dilating  Avedge  of  prolapsed  tissue. 

The  introduction  and  satisfactory  adjustment  of  the  Gehrung  pessary  re- 
quires considerable  study  and  experience.  In  introducing  the  pessary  the 
right  heel  is  grasped  in  the  fingers  of  the  right  hand,  as  shoAvn  in  Fig.  439,  A. 
The  upper  arch  is  beloAv.    With  the  right  heel  held  to  the  left  side  of  the  vulva, 


388 


GYNECOLOGIC    TREATMENT 


the  left  lieel  of  the  pessary  is  pushed  into  the  vaginal  opening  as  far  as  it  "will 
go  (Fig.  439,  B).  Then  the  right  heel,  still  grasped  in  the  fingers  of  the  right 
hand,  is  swnng  across  to  the  right  side  as  indicated  in  Fig.  440,  A.  This  brings 
uppermost  the  uj^per  arch  which  was  below,  and  causes  the  left  heel  of  the 
pessary  to  pass  under  the  cervix  (Fig.  440,  A)  to  the  patient's  left  side  (Fig. 


Fig.  440.  Introducing  the  Gehrung  pessary.  A.  Swinging  the  right  heel  to  the  right  side,  which 
carries  the  left  heel  under  the  cervix  to  the  left  side  and  brings  up  the  upper  arch,  which  was 
below.  B.  Pushing  the  pessary  around  the  vaginal  wall  back  of  the  cervix,  in  order  to  get  the  right 
heel   within   the    vagina.      C.    Further    progress    in    the    same    direction. 


Fig.  441.  Introducing  the  Gehrung  pessary.  A.  The  right  heel  within  the  vagina  and  being 
carried  to  its  position  on  the  right  side.  B.  The  two  heels  situated  symmetrically  on  each  side.  The 
arches  are  still  too  low.      C.   The  arches  pushed  up  into  place  back   of  the   symphysis. 


440,  B).  Now  the  pessary  is  pushed  in  farther,  the  left  heel  passing  around 
back  of  the  cervix  (Fig.  440,  C)  far  enough  to  permit  the  right  heel  to  slip  in- 
side (Fig.  440,  C).  The  right  heel  of  the  pessary  is  then  pushed  along  the 
vaginal  wall  to  the  right  side  (Fig.  441,  A),  until  the  right  and  left  heels  are 


USE    OF   PESSARIES 


389 


situated  symmetrically  on  each  side  of  the  vaginal  opening  (Fig.  441,  B).  The 
next  step  is  to  push  the  pessary  up  (Fig.  441,  B)  until  the  lower  arch  lies 
above  the  vaginal  opening  and  back  of  the  urethra,  and  the  upper  arch  sup- 
ports the  uterus  and  base  of  the  bladder  (Fig.  441,  C).  This  puts  the  sup- 
porting arches  in  the  position  shown  in  Fig.  438,  C,  and  the  heels  of  the  pes- 
sary take  hold  at  the  sides  of  the  vaginal  opening  as  indicated  in  Fig.  438,  D. 

If  the  heels  tend  to  slip  around  at  first,  a  little  tannic  acid  powder  may  be 
used  on  each  side,  to  prevent  slipping  until  the  heels  become  set. 

8.  Hewitt  Pessary.  This  pessary  consists  of  three  air-cushion  pessaries 
securely  fastened  together.  The  three  air-cushions  differ  in  size,  the  largest 
being  at  the  bottom  and  the  smallest  at  the  top  (Fig.  442,  A).  This  pyramidal 
air-cushion  acts  as  a  plug  to  block  the  vaginal  opening  (Fig.  442,  B)  and  pre- 
vent the  escape  of  the  uterus  or  bladder.  It  presents  the  following  advantages: 
(1)  the  superimposed  rings  give  a  pyramidal  shape  to  the  pessary  and  thus  it 


Fig.  442.     The   Hewitt    Pessary.      A.    Showing  the    construction    of    the    pessary — three    inflated    soft 

rubber    rings,    fastened    together.       B.    The    pessary  in    place,    showing    the    action    of    the    pyramid    in 

holding  up  the  uterus  and  the   base   of  the  bladder.  The   length   of   the   pessary   prevents   its   turning,    as 
does  the   ordinary   single-disk  pessary. 


holds  up  the  base  of  the  bladder  and  the  redundant  vaginal  walls  more  effect- 
ively than  a  single  ring;  (2)  the  added  length  prevents  the  pessary  turning 
and  hence  has  much  the  same  effect  as  the  stem  in  the  Menge  pessary;  (3)  the 
patient  herself  may  remove  the  pessary  for  cleansing  and  replace  it.  It  pre- 
sents the  following  disadvantages:  (1)  like  all  large  ring  pessaries,  it  has  the 
wedge  action  which  tends  to  stretch  the  vaginal  opening  and  cause  the  pes- 
sary to  work  out,  unless  so  large  as  to  make  uncomfortable  pressure;  (2)  its 
action  is  simply  that  of  a  ball-stopper  and  hence  it  must  necessarily  be  large 
and  heavy;  (3)  it  interferes  with  coitus  and  with  satisfactory  douching;  (4) 
being  of  soft  rubber,  it  must  be  removed  for  cleansing  very  frequently.  The 
Hewitt  pessary  in  action  and  effectiveness  is  about  like  the  Menge.  They  are 
each  inferior  to  the  Gehrung  pessary  in  effectiveness,  comfort  and  restoration 


390  GYNECOLOGIC    TREATMENT 

of  physiologic  function.  The  two  light  arches  of  the  Gehrung  pessary  give 
the  required  support  without  unnecessary  weight  and  without  plugging  the 
vagina.  Hence  sexual  intercourse  may  take  place,  effective  douching  is  pos- 
sible and  the  pessary  when  well  adjusted  may  be  worn  for  several  weeks  and 
even  for  several  months  without  removal.  But  the  other  two  pessaries  men- 
tioned are  much  more  easily  understood  and  hence  will  have  more  general 
use. 

9.  Cup  and  Belt  Pessary.  This  form  of  support  consists  of  an  abdominal 
belt  to  which  are  attached  rubber  cords  which  in  turn  hold  in  place  a  hard 
rubber  stem  and  cup  extending  into  the  vagina.  It  is  an  old  form  of  pessary 
which  sometimes  gives  much  relief  in  extreme  cases  in  which  every  form  of 
pessary  depending  on  the  pelvic  floor  for  support,  slips  right  out.  Of  course 
this  pessary  as  well  as  other  pessaries  are  only  makeshifts  giving  temporary 
relief,  and  curative  operative  procedures  are  indicated  in  suitable  cases.  But 
sOme  of  these  women  are  not  in  physical  condition  for  operation,  while  some 
others  refuse  operation,  preferring  to  get  along  with  a  fairly  satisfactory  pes- 
sary. A  modification  sometimes  useful  is  that  form  in  which  a  ball  is  substi- 
tuted for  the  cup  at  the  top  of  the  stem. 

X-RAY  TREATMENT,  ETC. 

Cauterization,  curettage,  electricity,  local  blood-letting  and  submucous  in- 
jections of  paraffin,  are  measures  which  have  occasionally  been  employed 
about  the  extcTnal  genitals  with  benefit.  Radium  and  the  Finsen  light  are 
used  but  little,  if  at  all. 

The  X-ray  has  proved  useful  in  quite  a  variety  of  gynecologic  affections. 
The  development  in  X-ray  work  has  become  so  extensive  in  the  last  few 
years  that  it  now  constitutes  a  specialty  in  itself.  The  results  depend  on  the 
accurate  selection  and  coordination  of  numerous  technical  details,  which 
vary  greatly  in  different  classes  of  cases.  The  best  results  can  be  secured  only 
by  one  thoroughly  familiar  with  the  therapeutic  use  of  the  X-ray  in  the 
various  affections.  The  treatment  is  not  given  a  fair  chance  when  applied 
in  a  haphazard  way  by  one  familiar  only  with  its  diagnostic  use.  This  fact 
should  be  kept  in  mind  in  every  estimation  of  X-ray  results. 

External  Genitals.  In  severe  pruritus  vulvae,  persisting  in  spite  of  other 
measures.  X-ray  treatment  has  effected  a  cure.  Even  when  the  process  has 
progressed  to  well  marked  kraurosis  vulvae,  this  treatment  as  a  rule  gives 
relief,  and  should  be  given  a  thorough  trial  before  resorting  to  excision  of  the 
external  genitals.  After  excision  the  process  may  appear  in  adjacent  surfaces, 
finally  requiring  X-ray  treatment  to  give  relief. 

In  tuberculosis  of  the  vulva,  in  ulcus  rodens,  and  in  chronic  eczema,  X-ray 
treatment  has  proved  exceedingly  useful.  In  any  chronic,  non-malignant  ul- 
ceration or  infiltration  that  resists  other  measures,  it  may  be  given  a  trial 
with  good  prospects  of  a  cure. 


INTRAUTERINE    TREATMENT  391 

111  malignant  disease,  however,  even  when  apparently  superficial,  opera- 
tion, including  wide  excision  of  the  lesion  and  its  lymphatic  field,  is  the  most 
certain  remedy.  The  X-ray  should  not  be  depended  on  in  inoperable  cases.  In 
inoperable  cases,  it  is  useful  in  retarding  growth  and  relieving  pain. 

Ovaries.  Under  the  influence  of  the  X-ray  the  ovaries  gradually  atrophy 
and  lose  their  function.  This  makes  it  useful  in  cases  of  excessive  ovarian 
activity,  as  in  sexual  hyperesthesia  (nymphomania).  In  addition  to  lessen- 
ing the  ovarian  activity  in  these  cases,  the  X-ray  may  be  applied  to  the  exter- 
nal genitals  to  diminish  the  congestion  and  hypersensitiveness  there. 

In  any  condition  in  which  it  is  advisable  to  diminish  ovarian  activity,  the 
X-ray  is  useful.  By  continuing  the  treatment  long  enough  the  patient  may 
be  rendered  permanently  sterile.  Thus  it  constitutes  a  two-edged  weapon — 
one  that  is  exceedingly  effective  in  various  directions  but  requires  much  care 
and  judgment  in  handling.  There  are  cases  in  which  sterilization,  with  the 
coincident  diminution  in  the  pelvic  blood  supply,  would  be  of  great,  benefit. 
While  in  other  cases,  for  varied  reasons,  any  effect  in  this  direction  must  be 
most  carefully  avoided. 

Uterus.  The  ovarian  effect  just  mentioned  tends  to  diminish  the  blood 
supply  of  the  uterus  aiid  thus  influences  favorably  pathologic  conditions  in 
that  region.  Cases  of  fibromyomata  are  generally  greatly  benefited  by  this 
treatment.  The  metrorrhagia  is  diminished  or  eliminated  and  in  many  cases 
there  is  marked  shrinking  in  the  size  of  the  tumor.  It  is  especially  indicated 
in  patients  not  in  good  condition  for  operation,  where  malignancy,  infection 
and  submucous  fibroid  can  be  excluded.  Of  course  this  treatment  means  a 
considerable  outlay  in  time  and  money,  and  even  then  operation  may  finally 
have  to  be  resorted  to.  The  cases  for  this  treatment  should  be  carefully  selected 
with  due  regard  to  the  contraindications.  Used  accurately,  by  one  experi- 
enced in  this  line  of  work,  it  is  useful  in  securing  relief,  more  or  less  perma- 
nent, in  inoperable  cases,  and  in  stopping  blood-loss  and  building  up  anemic 
patients  for  operation. 

Chronic  inflammation  of  the  uterus,  also,  with  the  congestion  and  metror- 
rhagia connected  therewith,  may  be  much  beneflted  by  X-ray  treatment. 
However,  the  sterilizing  ovarian  effect  must  be  kept  in  mind  and  eontrain- 
dicates  this  treatment  in  most  patients  in  the  child-bearing  period. 

INTRAUTERINE  TREATMENT 

MEDICATED  APPLICATIONS  WITHIN  THE  UTERUS 

Effects,  Good  and  Bad 

What  good  can  intrauterine  applications  do? 

They  may  exercise  an  antiseptic,  astringent  or  anesthetic  effect. 
They  may  destroy  diseased  tissue. 
They  may  exercise  a  hygroscopic  effect. 


392  GYNECOLOGIC    TREATMENT 

1.  They  may  exercise  an  antiseptic  or  astringent  or  anesthetic  effect, 

limited  to  the  surface  to  which  they  are  applied.  Owing  to  peculiarities  in  the 
nature  and  situation  of  the  endometrium,  an  intrauterine  application  of  an 
antiseptic  does  not  ordinarily  have  much  influence  in  checking  the  activity  of 
bacteria  that  have  gained  a  foothold  there.  The  three  most  important  influ- 
ences limiting  bacterial  penetration  into  the  uterine  wall  are  (a)  an  intact 
epithelial  surface,  (b)  the  bactericidal  influence  of  leukocytes  and  blood  serum 
and  lymph,  and  (c)  the  absence  of  irritation  (toxic,  chemical,  mechanical) 
within  the  cavity. 

In  a  patient  with  bacterial  invasion  of  the  endometrium,  after  the  uterus 
has  been  cleared  of  placental  remnants  and  good  drainage  secured  (removal  of 
toxic,  chemical  and  mechanical  irritation)  the  issue  depends  almost  wholly 
on  the  bactericidal  and  antitoxic  influence  of  the  leukocytes,  blood  serum 
and  lymph.  The  efficacy  of  any  therapeutic  measure  employed  must  be  judged 
largely  by  its  influence  on  this  battle  beneath  the  surface,  rather  than  by  any 
superficial  effect.  The  beneficial  effect  of  killing  a  few  bacteria  upon  the 
surface  is  more  than  overbalanced  by  the  local  disturbance  which  the  applica- 
tion occasions.  It  adds  irritation  to  the  already  great  irritation  from  the 
bacteria  and  their  products,  and  it  opens  up  new  avenues  for  invasion,  by 
abrasion,  of  the  protecting  epithelial  covering.  In  chronic  cases,  the  bad  effect 
of  such  applications  is  not  great,  because  nature  has  the  process  well  limited, 
but  occasionally,  even  in  these  cases,  there  will  be  considerable  disturbance 
following  the  application,  due  to  immediate  extension  of  the  infection  deeper 
into  the  uterine  wall  or  into  the  tubes  or  parametrium.  In  the  acute  and  sub- 
acute stages  of  bacterial  invasion  of  the  uterus  (puerperal  or  non-puerperal) 
an  intrauterine  application  very  frequently  causes  an  aggravation  of  the  trouble, 
as  evidenced  by  a  chill  and  a  sharp  rise  of  temperature  within  a  few  hours. 

It  may  be  stated  as  a  general  proposition,  that  intrauterine  applications  for 
antiseptic  effect,  in  the  acute,  subacute  or  chronic  stages  of  bacterial  invasion, 
do  more  harm  than  good.  The  harm  is  due,  not  to  the  presence  of  the  antiseptic, 
but  to  the  abrasions  of  the  endometrium  incident  to  the  application. 

If  the  antiseptic  effect  could  be  secured  without  these  minute  traumatisms, 
which  are  incident  to  the  introduction  of  any  instrument  within  the  cavity,  the 
applications  might  be  beneficial,  provided  they  are  made  in  an  aseptic  way. 
There  is  one  method  that  promises  something  along  this  line,  namely,  the  use 
of  uterine  suppositories,  of  such  consistency  that  they  can  not  abrade  the 
surface  of  the  endometrium.  . 

The  use  of  an  astringent  intrauterine  application  is  advisable  in  certain 
exceptional  cases  of  persistent  bleeding  or  free  discharge  from  the  endo- 
metrium, not  dependent  on  bacterial  invasion  or  a  new  growth.  There  are 
many  cases  of  bleeding  (especially  menorrhagia)  due  simply  to  chronic  con- 
gestion and  hyperplasia  of  endometrium.  It  is  principally  in  those  dependent 
on  subinvolution  and  which  have  not  been  relieved  by  internal  treatment  (laxa- 
tives,   general   tonics,   uterine   astringents)    and   hot   vaginal   irrigation   and 


INTRAUTERINE   TREATMENT  393 

other  measures  directed  towards  diminishing  the  pelvic  atony  and  congestion, 
that  local  astringent  applications  are  of  service. 

In  most  of  these  persistent  cases  it  is  preferable  to  remove  the  thickened 
endometrium  with  the  curet.  But  in  some  cases  the  symptoms  are  hardly 
sufficient  to  demand  curetment,  or  the  patient  objects  to  it.  In  such  a  case  a 
few  astringent  applications  to  the  endometrium,  mad©  under  proper  precau- 
tions, may  do  much  good  without  doing  damage.  A  few  abrasions  of  the  epi- 
thelium by  an  aseptic  application  in  such  a  case,  are  of  less  consequence  than 
when  made  in  an  infected  cavity  where  there  are  bacteria  ready  to  enter  the 
abrasions.  Also  the  chemical  and  mechanical  irritation  is  better  borne  because 
there  is  no  deep-seated  bacterial  activity.  The  discomforts  and  difficulties  of 
a  satisfactory  intrauterine  application  in  the  virgin  are  such  that  when  intra- 
uterine treatment  is  necessary,  thorough  dilatation  under  anesthesia  and  curet- 
ment is  usually  the  preferable  method. 

In  infective  endometritis,  the  application  will  probably  do  more  harm 
than  good,  except  in  those  old  cases  in  which  the  bacteria  are  dead  or  so  at- 
tenuated that  the  condition  is  practically  one  of  simple  endometritis. 

In  bleeding  due  to  fibroids  or  malignant  disease,  astringent  applications 
exercise  no  influence  over  the  course  of  the  disease,  and  may  cause  infection 
and  thus  increase  the  danger  of  the  necessary  operation.  For  temporary  con- 
trol of  bleeding  while  waiting  for  operation,  general  measures  and  internal 
medication  and  firm  vaginal  packing  will  nearly  always  suffice.  For  the  in- 
operable eases,  other  methods  more  effective  are  at  our  disposal. 

An  anesthetic  application,  such  as  cocaine  or  orthoform,  is  useful  when 
applied  about  a  sensitive  internal  os,  preceding  dilatation  of  the  same.  The 
pain  is  usually  considerably  diminished.  Applications  of  anesthetic  sub- 
stances to  the  endometrium  proper  are  of  little  benefit  and  present  the  dan- 
gers common  to  all  intrauterine  applications. 

2.  They  may  destroy  diseased  tissues.  This  will  be  spoken  of  under  cau- 
terization. 

3.  They  may  exercise  a  hygroscopic  effect.  This  effect,  secured  by  the 
small  amount  of  hygroscopic  material  retained  in  the  uterus,  is  so  slight  that 
intrauterine  applications  for  this  purpose  are  not  advisable. 

What  harm  can  intrauterine  applications  do? 

Same  that  vaginal  applications  may,  and  also :  .       . 

May  carry  infection  into  the  uterus. 

May  increase  bacterial  disturbance  already  in  the  uterus. 

1.  They  may  cause  the  same  harmful  effects  that  vaginal  applications 
may.  That  is,  they  may  (a)  cause  patient  to  come  to  office  when  she  should 
be  resting  at  home,  (b)  cause  postponement  of  effective  treatment  until  the 
disease  is  past  cure  and  (c)  convert  a  neurasthenic  or  hysteric  individual  into 
a  confirmed  invalid  by  fixing  attention  on  some  trivial  local  disturbance.- 

2.  They  may  carry  infection  into  the  uterus  and  change  some  simple  dis- 


394  GYNECOLOGIC    TREATMENT 

turbance  into  a  very  serious  one.  This  has  happened  many  times  and  con- 
stitutes one  of  the  most  serious  objections  to  intrauterine  applications.  By 
taking  proper  care  of  the  cervical  canal  with  an  antiseptic,  infection  can 
usually  be  avoided.  But  even  with  this  care,  infection  may  be  carried  in  from 
an  apparently  healthy  cervix.  It  is  an  ever-present  danger  and  must  be  over- 
balanced by  the  probable  benefit  in  the  particular  case,  before  an  intrauterine 
application  is  advisable. 

3.  They  may  increase  a  bacterial  disturbance  already  in  the  uterus,  as 
previously  explained. 

Methods  of  Intrauterine  Application 

1.  With  Cotton-wrapped  Applicator.  An  intrauterine  application  is  made 
by  wrapping,  with  disinfected  fingers,  a  small  amount  of  absorbent  cotton 
about  the  end  of  an  applicator  (Fig.  443,  b),  saturating  the  cotton  with  the 
desired  medicine  and  then  carefully  introducing  it  through  the  cleansed  and 
dilated  cervical  canal  into  the  cavity  of  the  corpus  uteri.  In  making  an  intra- 
uterine application,  the  same  antiseptic  care  must  be  observed  as  in  sounding 
the  uterus. 

It  is  well  to  prepare  a  number  of  cotton-wrapped  aluminum  applicators 
(Fig.  443,  c)  and  have  them  in  sterile  wide-mouthed  bottles  (Fig.  443),  some 
dry  sterilized  and  others  in  some  of  the  solutions  frequently  used.  Then  you 
can  be  certain  that  the  cotton  on  your  applicators  is  sterile,  as  it  is  very 
likely  not  to  be  if  it  is  twisted  on  hurriedly  during  the  office  treatment,  for 
it  is  difficult  to  sterilize  the  fingers  and  keep  them  sterile. 

2.  With  Gauze.  Another  method  and  a  very  effective  one  for  bringing 
medicine  in  contact  with  the  endometrium,  is  to  soak  the  end  of  a  small  strip 
of  antiseptic  gauze  in  the  medicine  and  carry  it  into  the  uterus  and  leave  it 
there.  The  remaining  part  of  the  gauze  is  packed  against  the  cervix  to  hold 
the  uterine  portion  in  place.  The  other  end  of  the  gauze  is  brought  near  the 
vaginal  outlet  so  that  the  patient  may  remove  it  after  several  hours. 

3.  Slippery-Elm  Applicator.  A  method  somewhat  similar  to  the  last  men- 
tioned, is  the  use  of  a  small  slippery  elm  tent,  sterilized  and  dipped  in  the 
medicine  and  carried  into  the  cavity  and  left  there.  A  string  is  attached  by 
which  the  patient  can  remove  it  as  directed. 

4.  Uterine!  Suppositories,  or  soluble  uterine  bougies,  furnish  another 
method  of  applying  medicine  to  the  endometrium.  Protargol  and  iodoform 
are  the  medicines  usually  incorporated  in  them. 

It  is  possible  that  there  will  be  worked  out  along  this  line,  a  method  of 
making  effective  antiseptic  and  astringent  applications  without  mechanical 
disturbance  of  the  endometrium.  If  so  this  might  prove  of  decided  help  in 
the  treatment  of  bacterial  invasion,  in  both  the  acute  and  chronic  stages.    The 


INTRAUTERINE   TREATMENT  395 

author  believes  that  more  will  be  accomplished  in  this  direction  by  using  the 
penetrating  antiseptics,  such  as  coUargolum  or  Crede's  ointment,  than  by  the 
use  of  the  surface  antiseptics  usually  employed. 


Fig.  443.  Applicators  for  Intrauterine  Treatment.  a.  The  ordinary  handled  applicator.  h.  The 
same  wrapped  with  cotton,  preparatory  to  dipping  it  into  the  medicine  to  be  applied  within  the^  uteius. 
c.  Plain  aluminum  wire  applicator,  nine  inches  long.  d.  The  same  wrapped  with  cotton.  The  jar  con- 
tains prepared   applicators   like    (d),   and   is   ready   to   receive   the   solution   in   which   they   are   to   be   kept. 

The  injection  of  medicines  into  the  uterine  cavity  by  means  of  the  intra- 
uterine syringe,  the  author  can  not  recommend.  Its  danger  outweighs  its  ad- 
vantages. 


396  GYNECOLOGIC    TREATMENT 

For  What  Effects  Indicated 

As  previously  explained,  the  only  intrauterine  applications  advisable 
ordinarily  are  those  for  an  astringent  or  anesthetic  effect  in  the  non-infected 
uterus,  and  even  these  only  in  exceptional  cases  and  for  a  short  time. 

Long  continued  intrauterine  applications  do  little  or  no  good  and  may  do 
much  harm.  They  may  cause  the  inflammation  to  extend  deeper  into  the 
uterine  wall  or  into  the  parametrium  or  into  the  Fallopian  tubes.  If  no  de- 
cided beneficial  effect  is  apparent  from  a  few  applications,  made  at  intervals 
of  several  days,  they  should  be  discontinued  and  more  effective  measures  em- 
ployed. 

Medicines  Used  for  Intrauterine  Application 

The  medicines  used  for  astring^ent  effect  are : 

Protargol,  5  to  10%. 

Formol,  20  to  40%. 

Iodized  Phenol  (Tinct.  iodine  and  carbolic  acid,  equal  parts). 

Carbolic  Acid,  10  to  95%. 

Copper  Sulphate,  10%. 
The  medicines  used  for  anesthetic  effect  are : 

Adrenalin  Chloride,  1-1000. 

Cocaine  Hydrochloride,  10  to  20%. 

Orthoform. 

Chloretone. 
Local  anesthetic  applications  are  seldom  used  within  the  uterus.  About 
the  only  indication  is  for  the  diminution  of  pain  due  to  dilatation  of  the  cervi- 
cal canal.  A  few  minutes  before  the  dilatation  an  application  of  the  desired 
local  anesthetic  is  made  along  the  canal,  especially  about  the  internal  os 
which  is  the  most  sensitive  part. 

HOT  AVATER  IRRIGATION 

Intrauterine  irrigation  is  employed  in  the  treatment  of  acute  endometritis, 
particularly  that  form  caused  by  infection  following  labor  or  abortion.  With 
the  same  antiseptic  precautions  as  for  sounding  the  uterus,  the  douche  cur- 
rent irrigating  tube  is  introduced  into  the  uterine  cavity  and  a  large  amount 
(half  a  gallon  to  a  gallon)  of  hot  sterile  water,  or  nomal  salt  solution,  is  al- 
lowed to  pass  slowly  through  the  uterus.  This  removes  mechanically  a  large 
amount  of  the  infective  material  and  the  effect  of  the  hot  water  is  beneficial 
in  tending  to  allay  the  inflammation.  In  some  cases  of  puerperal  sepsis,  this 
irrigation  is  sufficient  to  check  the  trouble,  but  in  other  cases  there  remains 
infected  material  that  must  be  removed  by  the  finger  or  curet.  One  thorough 
itrigation  is  usually  all  that  is. advisable  provided  the  uterine  cavity  drains 
well.    Of  course  if  there  is  distinct  retention  of  pus  within  the  uterus  then  the 


CAUTERIZATION    OP   ENDOMETRIUM  397 

cervix  must  be  opened  and  the  pus  washed  out  as  often  as  such  retention  oc- 
curs. Intrauterine  irrigation  has  been  used  also  in  the  treatment  of  acute 
gonorrheal  endometritis  but  the  effect  was  not  such  as  to  encourage  its  use. 

Prolonged  hot  intrauterine  irrigation  has  been  used  also  in  the  treatment 
of  chronic  endometritis  with  decided  benefit  in  some  cases.  In  the  uterus  not 
recently  pregnant,  the  cervix  may  require  considerable  dilatation  before  it 
will  admit  the  irrigating  tube.  The  required  dilatation  can  usually  be  easily 
accomplished  by  using  the  graduated  cervical  dilators,  of  hard  rubber  or  metal. 

In  addition  to  the  dangers  incident  to  all  intrauterine  manipulations  (ir- 
ritation, abrasions,  infection),  irrigation  presents  the  danger  of  fluid  extend- 
ing into  the  tubes  and  out  into  the  peritoneal  cavity.  To  avoid  this,  the  return- 
flow  must  be  unobstructed  and  the  irrigating  receptacle  not  more  than  two 
feet  above  the  uterus.  In  puerperal  infection,  after  the  uterus  is  thoroughly 
cleansed  of  placental  remnants  and  infected  clots,  and  free  drainage  is  secured, 
the  less  intrauterine  interference  for  irrigation  or  other  cause,  the  better  as 
a  rule. 

In  chronic  endometritis  the  treatment  by  intrauterine  hot  water  irriga- 
tion is  still  on  trial.  The  indications  so  far  are  that  in  the  cases  really  requir- 
ing intrauterine  treatment,  more  effective  methods  are  preferable. 

CURETMENT 

The  use  of  the  curet  within  the  uterus  in  office  work  is  very  limited.  It  is 
used  nearly  altogether  for  diagnostic  purposes,  though  occasionally  in  a  case 
of  hypertrophic  endometritis  with  a  wide  cervical  canal,  it  may  be  advisable 
to  curet  sufficiently  to  remove  a  large  part  of  the  endometrium  and  secure  a 
therapeutic  effect. 

The  precautions  are  the  same  as  for  sounding  the  uterus. 

Usually  the  Sims  posture  will  be  found  most  convenient. 

Regular  curetment  under  anesthesia,  properly  carried  out  in  suitable 
cases,  is  one  of  the  most  beneficial  of  gynecologic  therapeutic  measures.  By 
it,  the  chronically  diseased  endometrium  may  be  largely  removed.  This  stops 
the  bleeding  and  leaves  the  surface  in  a  good  condition  for  the  rapid  regenera- 
tion of  a  comparatively  healthy  endometrium.  In  practically  all  cases  of 
chronic  uterine  bleeding  or  free  discharge,  in  which  the  trouble  is  not  amen- 
able to  a  few  intrauterine  applications,  regular  curetment  under  anesthesia  is 
indicated  both  for  therapeutic  effect  and  for  diagnosis.  Regular  curetment  is 
considered  in  detail  in  Chapter  vi  under  Chronic  Endometritis. 

CAUTERIZATION  OF  ENDOMETRIUM 

Destruction  of  the  endometrium  by  cauterization  was  formerly  much  prac- 
ticed in  cases  of  persistent  bleeding  or  discharge.  It  has  been  found,  however, 
that  in  all  but  exceptional  cases,  a  curetment  is  more  effective  and  leaves  the 


398     '  GYNECOLOGIC    TREATMENT 

uterus  in  better  condition  for  the  regeneration  of  a  healthy  endometrium,  as 
explained  and  illustrated  in  Chapters  vi  and  xv. 

In  cases  where  curetment  can  not  be  carried  out  or  is  not  effective,  cauteri- 
zation may  be  employed.  For  accomplishing  this  there  are  three  methods — by 
chemicals,  by  steam,  by  electricity. 

Cauterization  of  Endometrium  by  Chemicals.  Chloride  of  zinc  was  form- 
erly much  used,  as  was  also  nitric  acid.  The  effect  of  these  strong  deeply  cau- 
terizing agents  in  many  cases  was  to  destroy  the  endometrium  beyond  the  pos- 
sibility of  satisfactory  regeneration,  the  interior  of  the  uterus  being  in  many 
cases  converted  into  a  mass  of  scar-tissue. 

Carbolic  acid  (95%)  does  very  well  as  a  superficial  cauterant,  but  it  does 
not  cauterize  deeply  enough  to  approach  in  effectiveness  curetment  as  a  means 
of  removing  a  diseased  and  bleeding  endometrium.  AVhen  a  superficial  effect 
only  is  required,  it  does  very  well,  applied  as  an  ordinarj'-  medicated  intra- 
uterine application.  Care  is  necessary,  however,  to  avoid  cauterizing  the 
vaginal  wall  and  also  to  avoid  concentrating  the  effect  in  the  narrow  part 
of  the  cervical  canal,  near  the  internal  os,  with  almost  no  effect  above.  This 
is  avoided  by  having  the  cervical  canal  well  dilated,  so  the  charged  applicator 
will  pass  in  easily. 

The  stronger  formol  solutions  (30%  to  50%)  have  a  superficial  cauterizing 
effect. 

Cauterization  of  Endometrium  by  Steam.  By  means  of  the  Pincus  ap- 
paratus, the  intrauterine  application  of  steam  has  been  made  practical.  A 
thorough  curetment  (under  anesthesia)  precedes  the  application  of  steam. 
Then  the  steam,  under  the  control  of  the  Pincus  apparatus,  is  applied  for  a 
few  seconds.  This  cauterizes  the  interior  of  the  uterus,  and  stops  metror- 
rhagia in  some  cases  where  other  measures,  including  repeated  curetment, 
have  failed. 

It  is  a'  dangerous  measure,  however,  and  is  not  suitable  for  general  use. 
It  has  caused  deaths,  also  atresia  of  the  uterine  canal  necessitating  subsequent 
hysterectomy.  It  is  not  to  be  used  as  a  substitute  for  curetment  or  other  less 
dangerous  measures,  but  is  to  be  employed  only  as  a  substitute  for  hysterectomy 
in  eases  of  persistent  metrorrhagia  due  to  a  non-malignant  pathologic  process 
in  the  endometrium.  In  most  cases  of  this  sort  at  present  preference  is  given 
to  the  application  of  radium  or  X-rays. 

Cauterization  of  Endometrium  by  Electricity.  This  is  often  very  effective 
where  a  mild  cauterizing  effect  is  desired,  to  check  a  persistent  menorrhagia 
or  metrorrhagia  not  dependent  on  malignant  disease  nor  active  infection.  The 
treatments  may  be  given  in  the  office  easily  and  with  but  little  discomfort  to 
the  patient  in  suitable  cases.  "Where  curetment  is  not  required  for  diagnosis, 
electricity  may  in  some  cases  be  used  as  an  effective  substitute  for  it,  and  anes- 
thesia thus  avoided. 

The  details  of  the  application  of  electricity  in  this  and  other  cases  are 
given  below. 


ELECTRICITY  399 


ELECTRICITY 


Electricity  is  a  useful  method  of  treatment  which  has  fallen  into  disre- 
pute because  too  much  was  expected  of  it  and  claimed  for  it.  The  manner,  of 
its  presentation  was  confusing  and,  with  the  small  results,  discouraging.  It 
was  put  forward  as  a  wonderful  cure-all,  with  a  mysterious  source,  action 
and  effect.  Its  clinical  use  and  understanding  supposedly  necessitated  the  pe- 
rusal of  volumes  of  explanations — sensible  and  absurd,  Chemical,  physical, 
physiologic  and  psychic.  By  the  time  the  reader  had  made  good  progress 
into  the  explanations,  he  was  so  bewildered  and  befuddled  that  the  only  tan- 
gible conclusion  he  could  reach  was  that  it  was  a  wonderful  remedy  and  must 
certainly  produce  wonderful  results  for  whatever  used. 

When  the  actual  clinical  results  were  viewed  in  the  same  way  that  results 
from  therapeutic  measures  without  mysterious  trimmings  were  viewed,  it  was 
found  that  many  of  the  strongest  claims  were  without  foundation  in  fact. 

Because  of  this  conspicuous  failure  in  certain  particulars,  some  have  been 
led  to  the  mistaken  idea  that  it  is  a  total  failure  as  a  therapeutic  agent.  Less 
of  mystery  and  finely-spun  theorizing  and  more  of  common  sense  and  critical 
testing  of  results  by  reliable  methods,  have  shown  that  its  usefulness  in  strictly 
gynecologic  cases  is  very  limited,  but  within  those  limits  it  is  effective. 

Apparatus  Required 

It  is  necessary  to  have  an  electrical  table-plate  or  switch-board  arranged 
for  delivering,  controlling  and  measuring  the  current,  and  a  separate  converter 
for  the  cautery.  The  current  itself  is  preferably  supplied  from  a  suitable  street 
current,  if  that  is  available.  In  places  where  there  is  no  street  current,  de- 
pendence must  be  placed  in  cells  of  suitable  character  and  number,  placed  in 
the  basement  or  elsewhere. 

Electrodes.  There  should  be  one  large  abdominal  electrode  made  of 
sponge  or  some  satisfactory  substitute.  Just  before  using  each  time  the  sur- 
face of  the  electrode  may  be  covered  with  a  layer  of  absorbent  cotton,  which 
keeps  it  from  direct  contact  wdth  the  skin  of  the  patient  and  thus  does  away 
with  any  possibility  of  contamination  from  one  person  to  another.  By  using 
a  wide,  thick  piece  of  absorbent  cotton,  the  contact  surface  of  the  electrode 
may  be  increased  as  desired.  This  increase  in  contact  surface  is  very  useful 
for  the  abdominal  electrode  when  giving  strong  currents. 

Two  VAGINAL  electrodes,  One  monopolar  and  one  bipolar,  are  required. 
These  may  be  used  also  as  rectal  electrodes. 

Two  INTRAUTERINE  ELECTRODES,  One  monopolar,  and  one  bipolar,  are  re- 
quired. They  must  be  so  constructed  that  they  can  be  sterilized  each  time 
before  use.  The  intrauterine  electrodes  may  be  used  also  as  urethral  elec- 
trodes. 

A  very  convenient  set  of  monopolar  electrodes  is  that  of  Goelet's.     There 


400  GYNECOLOGIC    TREATMENT 

are  three  sizes  in  order  to  make  them  effective  in  the  treatment  of  cervical 
stenosis  and  persistent  menorrhagia  and  metrorrhagia. 

In  the  treatment  of  persistent  uterine  bleeding  the  effect  desired  is  a 
mild  cauterization  of  the  endometrium.  This  is  secured  as  later  explained  by 
a  current  of  30  to  40  m.  a.,  the  intrauterine  electrode  being  the  positive  pole. 
When  the  positive  pole  is  composed  of  copper  it  is  corroded  by  the  current  and 
there  is  secured  some  cataphoresis — that  is,  the  copper  salts  are  projected 
slightly  into  the  adjacent  tissues,  increasing  the  beneficial  effect. 

For  regular  cautery  work  (excision  of  growths,  etc.)  it  is  necessary  to 
have  a  cautery  handle  with  two  cautery  points,  one  point  knife-like,  for  cut- 
ting, and  the  other  cone-shaped  for  touching  surfaces  superficially. 

Rules  of  Application 

1.  Study  Your  Electrical  Outfit  and  experiment  with  it  until  you  are  ac- 
quainted with  all  its  component  parts  and  know  by  experience  what  it  will  do 
under  ordinary  circumstances.  You  can  not  get  this  knowledge  by  reading  a 
description  of  the  apparatus  and  the  directions  for  operating  it.  It  can  be 
acquired  only  by  actually  handling  and  experimenting  with  it. 

2.  Wherever  an  electrode  is  to  be  applied  to  the  skin,  the  skin  and  the 
electrode  should  be  well  moistened.  If  this  precaution  is  not  taken,  there  will 
be  considerable  pain  and  not  much  current,  for  the  dry  skin  is  a  poor  con- 
ductor of  electricity. 

See  that  there  is  no  current  until  everything  is  in  place.  Adjust  the 
electrodes  in  place  before  connecting  them  with  the  battery.  When  connect- 
ing them  with  the  battery  see  that  the  current  is  entirely  shut  off. 

3.  After  the  electrodes  are  in  place  and  connected  by  the  conducting 
cords  with  the  battery,  then  by  means  of  the  current  controller  turn  the  cur- 
rent on  very  gradually.  If  the  patient  complains  of  pain  while  there  is  only  a 
small  current,  it  means  that  there  is  poor  contact  or  too  small  an  area  of  con- 
tact between  one  of  the  electrodes  and  the  patient.  If  the  indicator  of  the 
milliamperemeter  fails  to  move  up,  it  means  that  there  is  a  break  somewhere 
and  that  there  is  no  current  passing  between  the  electrodes.  Turn  on  only  a 
very  small  current  until  it  is  seen  that  everything  is  working  nicely  and  then 
the  strength  may  be  gradually  increased  to  the  desired  amount. 

4.  Indifferent  Electrode.  In  all  pelvic  applications,  where  two  electrodes 
are  used,  the  larger  electrode  is  placed  on  the  lower  abdomen  or  on  the  back 
in  the  lumbar  or  sacral  region.  It  is  disposed  in  relation  to  the  active  elec- 
trode so  that  the  current  will  pass  through  the  affected  tissues.  Consequently, 
in  most  cases  it  is  placed  over  the  lower  abdomen.  This  large  electrode  is 
called  the  indifferent  electrode  because  there  is  no  particular  effect  near  it. 
It  must  be  large  enough  (must  spread  over  enough  skin  surface),  to  carry  the 
required  strength  of  current  without  marked  irritation  of  the  surface.  If 
the  contact  area  is  too  small  for  the  strength  of  current,  the  skin  becomes  very 


ELECTRICITY  401 

red  and  the  patient  complains  of  tingling  oi*  burning.  In  cases  where  a 
counterirritant  effect  on  the  skin  is  desired,  a  strong  current  with  an  under- 
sized electrode  may  be  used  for  that  purpose.  Ordinarily,  however,  the  in- 
different electrode  should  be  so  large  that  there  is  no  effect  on  the  skin  beyond 
a  slight  tingling  and  a  temporary  redness.  If  any  metal  part  of  an  abdominal 
electrode  conies  in  contact  Avith  the  skin,  while  a  strong  current  is  passing,  it 
will  cause  a  burn  and  resulting  blister. 

5.  The  Active  Electrode  is  the  internal  one,  the  one  in  the  uterus  or  vagina 
or  urethra  or  rectum  as  the  case  may  be.  If  the  application  is  wholly  external, 
the  smaller  of  the  two  electrodes  is  the  active  one  and  is  usually  placed  near- 
est the  seat  of  the  lesion  or  the  pain  (the  external  applications  are  usually 
made  for  pain),  the  larger  electrode  (indifferent  electrode)  being  placed  op- 
posite on  the  abdomen  or  on  the  back. 

The  internal  electrodes  (intrauterine,  vaginal,  urethral,  rectal)  are  ordi- 
narily used  bare  so  that  the  metal  comes  in  direct  contact  with  the  adjacent 
surface.  In  cases  of  vagino-abdomnial  or  vagino-dorsal  application  in  which 
it  is  desired  to  use  a  strong  current,  the  vaginal  electrode  is  wrapped  with  ab- 
sorbent cotton  which  is  well  moistened  before  introduction.  By  increasing  the 
amount  of  the  wrapping,  the  contact  surface  of  the  vaginal  electrode  (and 
consequently  the  strength  of  the  current  that  may  be  used  Avithout  discomfort) 
may  be  increased  as  desired. 

*6.  The  active  electrode  is  the  positive  pole  when  it  is  giving  the  current 
to  the  other  one,  it  is  the  negative  pole  when  it  is  receiving  the  current  from 
the  other  one. 

The  active  electrode  is  made  positive  or  negative  as  desired  by  means  of 
the  pole  changer. 

7.  The  Local  Effects  of  the  positive  pole  are  to  diminish  the  amount  of 
blood  in  the  immediately  adjacent  tissues  (checks  hemorrhage  and  lessens 
congestion)  and  to  relieve  pain.  It  is  used  to  check  uterine  bleeding  due  to 
endometritis,  subinvolution,  or  fibroids,  and  to  relieve  pain  due  to  congestion, 
old  inflammatory  trouble  or  neuralgia. 

The  local  effects  of  the  negative  pole  are  to  increase  the  amount  of  blood 
in  the  immediately  adjacent  tissues.  Consequently,  it  causes  active  conges- 
tion, increases  functional  activity,  increases  growth  and  hastens  the  absorp- 
tion of  chronic  exudates.  It  is  used  in  cases  of  amenorrhea,  scanty  menstrua- 
tion, poor  development  of  uterus  or  ovaries,  and  for  plastic  or  serous  exudates 
remaining  in  the  pelvis  after  acute  symptoms  have  long  subsided. 

The  relative  quality  of  action  of  the  tAvo  poles  is  about  the  same  for 
both  the  galvanic  and  faradie  currents. 

8.  With  the  Faradie  Current,  one  may  use  either  the  primary  or  secondary 
current. 

The  primary  current  is  more  stimulating  and  is  used  to  overcome  relaxa- 
tion of  tissues  and  to  increase  functional  activity. 

The  secondary  current  is  more  sedative  in  its  effect  and  is  used  to  relieve 


402  GYNECOLOGIC    TREATMENT 

pain  due  either  to  congestion  or  to  nenralgic  conditions.  AYitli  tlie  faradic 
current  there  is  anotlier  disposition  of  the  poles,  namely,  the  placing  of  the 
two  close  together  in  the  same  electrode.  This  constitutes  the  bipolar  electrode. 
Used  with  the  secondary  current,  it  is  especially  effective  in  relie^dng  local 
pain. 

9.  The  various  locations  of  the  electrodes  for  pelvic  treatment  may  be 
designated  as  follows : 

On   External   Surfaces — Dorso-abdominal,    Sacro-abdominal,    Perineo-ab- 

dominal,  Perineo-dorsal. 

In  Vagina — Vagino-abdominal,  Yagino-dorsal,  Bipolar  vaginal. 
In    Uterus — Intrauterine-abdominal,    Intrauterine-dorsal,    Bipolar    intra- 
uterine. 
In  Rectum — Eecto-abdominal,  Eecto-dorsal,  Bipolar  rectal. 
In  Urethra — Urethro-abdominal,  Urethro-dorsal,  Bipolar  urethral. 

Other  methods  of  application  such  as  general  galvanization  and  general 
faradization  and  applications  of  static  electricity,  while  frequently  useful  in 
the  treatment  of  certain  conditions  associated  with  gynecologic  diseases,  be- 
long to  general  medicine  and  will  not  be  described  here. 

10.  Manner  of  using  electricity  for  the  different  affections. 

a.  For  uterine  bleeding  (menon-hagia  or  metrorrhagia),  uterine  leucor- 
rhea  or  chronic  congestion,  use  the  galvanic  current,  positive  pole  in  uterus, 
strength  of  current  20  to  50  ma.  duration  five  to  ten  minutes,  and  repeat  once 
a  week  or  twice  a  week  or  every  other  day  as  necessary. 

b.  For  amenorrhea,  scanty  menstruation,  poorly  developed  uterus,  atonic 
conditions  of  uterus  or  vagina  or  pelvic  floor  muscles  or  sphincter  ani  (when 
repaired  after  long  non-use)  or  sphincter  vesicae  (when  weak  from  damage  in 
parturition  or  other  cause),  use  the  galvanic  current,  negative  pole  in  uteras, 
strength  of  current  20  to  50  ma.,  duration  five  to  ten  minutes,  and  repeat 
once  a  week  or  twice  a  week  or  every  other  day  as  necessary. 

Use  faradic  current,  primary  current  and  negative  pole  in  uterus. 

Use  faradic  current,  primary  current    and  negative  pole  in  vagina. 

Use  faradic  current,  bipolar  application  in  uterus  or  vagina. 

In  all  cases  be  very  careful  to  exclude  pregnancy  before  using  this  treat- 
ment. When  treating  for  atony  of  the  sphincter  ani  and  accessory  muscles, 
the  vaginal  electrodes  may  be  used  as  rectal,  the  active  portion  of  the  elec- 
trode being  placed  so  as  to  direct  the  current  through  the  affected  muscles. 
When  treating  for  imperfect  control  of  the  urine,  the  intrauterine  electrodes 
may  be  used  as  urethral. 

c.  To  overcome  stenosis  of  cervical  canal,  use  galvanic  current,  negative 
pole,  strength  of  current  5  to  10  ma.,  duration  10  to  20  minutes  and  use  twice, 
with  a  3  to  5  day  interval,  just  before  the  menstrual  time,  when  no  chance  of 
pregnancy. 


ELECTRICITY  403 

The  electrode  is  introduced  to  the  stenosis  and  then  the  current  turned 
on  gradually.  The  effect  of  the  negative  pole  is  to  cause  congestion  and 
softening  of  the  tissues.  The  electrode  is  kept  gently  pressed  against  the  area. 
It  gradually  advances  as  the  tissues  in  front  of  it  soften. 

d.  To  relieve  pain  due  to  dysmenorrhea,  chronic  pelvic  inflammation  or 
congestion,  use  the  positive  pole  in  the  uterus  or  vagina  with  galvanic  or 
faradic  current.  Also  faradic  bipolar  application  with  secondary  current.  If 
due  to  anemia,,  poor  development  or  poor  functional  activity,  use  the  nega- 
tive pole  in  uterus  or  vagina  with  galvanic  or  faradic  secondary  current.  Also 
faradic  bipolar  application  in  uterus  or  vagina  with  secondary  current.  If 
without  distinct  local  lesion,  i.e.,  coming  under  the  class  styled  neuralgic,  try 
the  different  methods.  The  faradic  bipolar  application  with  secondary  cur- 
rent is  especially  effective  in  relieving  localized  pain,  when  the  electrode  can 
be  brought  close  to  the  painful  area.  The  advice  to  try  the  different  methods 
is  applicable,  in  a  measure,  in  nearly  all  applications  of  electricity  to  gyne- 
cologic treatment,  when  the  method  first  used  does  not  produce  the  desired 
result.  Each  case  is  to  some  extent,  a  ''mixed  case,"  i.e.,  there  are  several 
separate,  and  sometimes  opposed,  factors  at  work  and  it  is  often  difficult  to  say 
which  is  the  predominating  one. 

e.  For  excision  or  destruction  of  tissue,  such  as  small  condylomata  about 
the  external  genitals,  caruncle  about  the  urethra,  persistent  erosion  about  the 
cervix,  small  cervical  cysts,  cervical  polypi,  etc.,  the  cautery  is  employed.  Use 
the  cautery-knife  for  excising  papillomata  and  puncturing  cysts,  and  the  cone- 
shaped  cautery-point  for  searing  areas  requiring  such  treatment.  If  on  a 
sensitive  surface,  as  on  the  external  genitals  or  on  the  vaginal  wall,  apply  a 
20  per  cent  cocaine  solution  or  inject  a  one-half  per  cent  cocaine  solution  at 
the  base  of  the  involved  tissue. 

11.  The  desired  effect  should  be  obtained  with  as  little  local  disturbance 
as  possible — that  is,  in  a  case  where  the  desired  result  can  be  obtained  by 
clorso-abdominal  applications  (as  in  some  cases  of  general  pelvic  pain  due  to 
chronic  pelvic  inflammation,  pelvic  neuralgia,  etc.)  these  should  be  used  in 
preference  to  vaginal  or  intrauterine  applications,  especially  in  the  case  of 
unmarried  women.  On  the  same  principle,  an  intrauterine  application  is  not 
used  when  a  vaginal  application  will  suffice. 

Furthermore  the  strength  of  the  application  should  not  be  such  as  to 
cause  pain,  the  limit  for  that  particular  patient  being  found  by  gradual  in- 
crease of  the  current  strength  by  means  of  the  controller  (rheostat).  Start 
with  a  very  slight  current,  barely  enough  to  move  the  indicator,  until  it  is 
seen  that  everything  is  working  smoothly.  Then  increase  very  gradually  as 
the  patient  becomes  accustomed  to  the  current.  This  special  care  to  give  not 
the  slightest  discomfort  is  particularly  important  at  the  first  application,  as 
some  patients  are  very  uneasy  when  under  treatment  by  electricity  until  it 
has  been  demonstrated  to  them  that  there  is  no  pain  or  shock. 

The  duration  of  the  application  should  not  be  sufficient  to  cause  fatigue 


404  GYNECOLOGIC    TREATMENT 

or  much  subsequent  irritation,  the  usual  duration  being  10  to  20  minutes. 
The  frequency  of  the  application  varies  very  much  in  different  cases.  The 
milder  application  may  be  made  twice  a  week  or  every  other  day  or  even 
every  day  for  special  indications.  The  stronger  currents  should  be  applied 
less  frequently,  as  once  a  week  or  every  ten  days  or  two  weeks. 

12.  Strict  attention  should  be  given  to  icleanliness.  The  electrodes  for 
internal  use  (intrauterine,  vaginal,  urethral,  rectal)  are  sterilized  and  used 
under  the  same  strict  precautions  as  other  instruments  for  the  same  localities. 

13.  Eemember  that  electricity  is  not  a  cure-all.  It  is  only  one  of  our 
many  resources.  Some  affections  in  some  patients  are  benefited  by  it.  Many 
are  not  benefited.  Our  duty  in  each  case  of  disease  is  to  cure  the  patient,  or 
give  her  relief,  by  the  safest  and  most  effective  means.  Consequently  in  those 
cases  where  electricity  promises  the  best  results  it  should  be  given  a  thorough 
trial,  but  in  those  cases  for  which  we  have  better  means  no  time  should  be 
wasted  with  it. 

CERVICAL  DILATATION 

The  thorough  dilatation  under  anesthesia  which  precedes  curetment  is  con- 
sidered in  Chapter  vi. 

Partial  dilatation  in  the  oi^ce  may  give  considerable  relief  in  cases  of 
dysmenorrhea  and  it  is  used  also  in  the  treatment  of  sterility.  The  methods 
of  making  partial  dilatation  are  given  in  Chapter  i  and  in  Chapter  xiv. 

VACUUM  TREATMENT 

Suction  has  been  applied  to  the  uterine  cavity  by  means  of  an  apparatus 
fitting  over  the  cervix  and  extending  into  the  cavity.  By  means  of  a  suction 
pump  the  uterine  secretion  is  drawn  out  and  a  partial  vacuum  created,  caus- 
ing passive  congestion  of  the  endometrium.  It  is  an  application  of  Bier's 
''congestion  treatment,"  which  has  been  found  so  useful  in  certain  general 
surgical  affections.  It  has  been  used  principally  in  the  treatment  of  chronic 
endometritis.  The  reported  cases  show  that  the  treatment  must  be  long  con- 
tinued and  the  results  finally  secured  are  apparently  no  better,  if  as  good,  as 
those  given  by  the  more  common  and  less  tedious  therapeutic  methods. 


APPLICATIONS  WITHIN  RECTUM 

ENEMATA,  LOW  AND  HIGH 

The  use  of  low  enemata  for  emptying  the  rectum  is  so  common  and  well 
known  as  to  require  no  description.  It  may  be  well,  however,  to  point  out 
that  in  all  painful  affections  of  the  rectum,  an  enema  of  two  to  four  ounces  of 
olive  oil  or  sweet  oil,  with  or  without  the  addition  of  a  pint  of  plain  water,  is 
preferable  to  the  soap-water  enema  ordinarily  employed. 


PELVIC    MASSAGE  405 

High  enemata  are. useful  in  several  ways.  Plain  Avater  or  soap-water  or 
medicated  solutions  are  used  in  this  way  to  secure  bowel  movement  in  ob- 
stinate eases.  Normal  saline  solution  is  thus  used  after  serious  operations, 
to  relieve  thirst,  to  aid  the  kidney  action  and  to  sustain  the  heart.  Various 
nutrient  mixtures  are  used  as  high  enemata  to  nourish  the  patient  in  certain 
classes  of  cases. 

It  is  in  the  after-treatment  of  serious  operative  cases  that  high  enemata 
are  principally  employed  in  gynecologic  work.  The  indications  for  their 
employment  are  given  under  After-treatment  of  Operative  Cases  (Chapter 
XVII ). 

HOT  WATER  IRRIGATION  OF  RECTUM 

The  use  of  hot  water  or  hot  saline  solution  in  the  rectum  has  been  found 
useful  in  two  classes  of  gynecologic  cases,  first,  those  presenting  a  large 
mass  of  inflammatory  exudate  that  resists  absorption  and,  second,  those  pre- 
senting acute  general  peritonitis. 

For  Pelvic  Exudate.  In  these  cases  the  effect  desired  is  the  same  as  that 
sought  by  the  long  hot  vaginal  douche,  namely,  the  long  application  of  moist 
heat  in  the  immediate  vicinity  of  the  mass  of  exudate.  In  some  cases  the  hot 
Avater  may  be  brought  closer  to  the  mass  and  made  more  effective  by  rectal 
irrigation  than  by  vaginal  irrigation.  The  rectal  douche  must  differ,  however, 
in  some  particulars  from  the  vaginal  douche.  On  account  of  the  sphincter  ani 
muscle,  a  double  irrigating  tube  should  be  used.  Again,  the  rectal  mucosa  is 
easily  irritated  and,  furthermore,  it  is  an  absorbent  surface,  hence  no  strong 
antiseptic  solution  is  permissible  there.  The  irrigating  fluid  should  be  simply 
plain  water  or  normal  saline  solution. 

For  Sepsis.  Here  the  effect  desired  is  absorption  of  the  saline  solution 
into  the  general  circulation,  for  aiding  the  kidneys  and  heart,  and  also  to  some 
extent  absorption  of  the  saline  into  the  peritoneal  cavity  and  out  with  the 
drainage,  instead  of  absorption  of  septic  material  from  the  cavity  into  the 
general  circulation.  For  details,  see  Treatment  of  Acute  Pelvic  Inflammation 
(Chapter  x). 

APPLICATIONS  TO  THE  LOWER  ABDOMEN  AND  INTERIOR 

OF  PELVIS 

PELVIC  MASSAGE 

Pelvic  massage  is  the  application  of  the  principles  of  massage  to  the  intra- 
pelvic  structures. 

The  effects  to  be  attained  are: 

Correction  of  displacement  of  the  uterus,  tubes  and  ovaries. 

Stretching  of  adhesions  and  infiltrated  tissues. 

Improvement  of  pelvic  circulation  (lymph  and  blood). 

Absorption  of  chronic  exudates. 


406  GYNECOLOGIC    TREATMENT 

Details  of  Application 

Tlie  author  believes  the  best  way  to  introduce  this  important  therapeutic 
method  is  to  consider  it  as  a  continuation  of,  or  addition  to,  the  ordinary  bi- 
manual examination.  When  there  is  displacement  of  the  uterus,  with  or  with- 
out adhesions,  the  bimanual  examination,  by  which  the  diagnosis  is  established, 
has  also  a  therapeutic  value. 

Take,  for  example,  a  case  of  retrodisplacement  in  which  the  uterus  can 
be  brought  forward  but  will  not  stay  there.  By  bringing  the  uterus  forward 
in  the  bimanual  examination,  the  diagnosis  of  movable  retrodisplacement  is 
established.  Then  search  is  made  to  discover  why  the  uterus  will  not  stay  for- 
ward. Suppose  it  is  found  that  the  anterior  vaginal  wall  or  vesico-vaginal 
septum  is  shortened,  as  sometimes  happens.  Whether  this  is  a  primary  or 
secondary  change  is  not  of  so  much  importance  as  to  the  fact  that  it  exists, 
and  constantly  keeps  the  cervix  so  far  forward  that  the  fundus  uteri  tends  to 
go  backward.  Of  course,  when  in  the  bimanual  examination  the  fundus  is 
brought  forward,  the  cervix  is  pushed  backward  and  upward  and  the  fundus 
is  at  the  same  time  bent  forward  over  the  tips  of  the  examining  fingers  in  the 
anterior  fornix,  to  take  out  any  flexion  in  the  body  of  the  uterus. 

Now,  if  instead  of  ceasing  this  intrapelvic  work  as  soon  as  the  diagnosis 
is  established,  we  continue  to  stretch  the  shortened  vesico-vaginal  septum,  a 
decided  therapeutic  effect  tending  to  permanent  correction  of  the  displacement 
is  secured.  The  contracted  tissues  anterior  to  the  cervix  are  made  tense  and 
stretched  even  up  to  the  point  of  painfulness,  and  we  endeavor  all  the  time  to 
place  the  cervix  farther  back  in  the  pelvis  as  the  tissues  gradually  yield. 
Force  sufficient  to  damage  the  tissues  or  cause  severe  pain  should  not  be  used, 
the  object  being  to  gradually  lengthen  the  tissues  as  much  as  possible  without 
damage.  In  doing  this  we  perform  one  of  the  important  manipulations  of 
pelvic  massage,  namely,  stretching'.  This  stretching  may  be  done  with  the 
vaginal  fingers  alone,  but  the  holding  of  the  fundus  uteri  well  forward  at  the 
same  time,  Avith  the  fingers  of  the  abdominal  hand,  makes  it  more  effective. 
There  may  be  a  restricting  band  running  obliquely  toward  one  obturator  fora- 
men, or  transversely  toward  the  pelvic  wall  in  the  base  of  the  broad  ligament. 
Whatever  the  direction  of  the  band,  it  is  to  be  stretched. 

This  process  oi  stretching  is  somewhat  painful  and  may  be  followed  by  a 
sense  of  fullness  and  pain  in  the  stretched  structures.  It  has  been  found  by 
experience  that  these  discomforts  are  diminished  and  the  softening  and  stretch- 
ing of  the  tense  tissues  facilitated  by  sweeping  pressure,  so  directed  as  to  work 
the  lymph  and  venous  blood  out  of  the  tissues  toward  the  pelvic  wall.  This 
permits  the  more  rapid  entrance  of  fresh  blood  and  hastens  the  absorption 
of  serous  and  cellular  infiltration.  This  sweeping  pressure  is  applied  by  the 
finger-tips  or  the  knuckles  of  the  abdominal  hand,  Avorked  far  down  into  the 
pelvis  to  the  tissues  under  treatment.  The  fingers  of  the  abdominal  hand  de- 
press the  abdominal  wall  to  the  affected  tissues,  which  tissues  are,  at  the  same 


PELVIC    MASSAGE  407 

time,  raised  as  much  as  possible  by  the  vaginal  fingers.  The  infiltrated  tissues 
are  now  compressed  betAveen  the  vaginal  and  abdominal  fingers.  The  abdom- 
inal fingers,  still  keeping  up  the  pressure,  are  made  to  describe  a  small  circle 
or  ellipse.  In  the  lower  part  of  the  circle,  which  lies  directly  over  the  tissues 
under  treatment  and  where  the  direction  of  movement  is  from  within  outward, 
the  strong  pressure  is  made.  In  this  movement,  the  abdominal  fingers  remain 
at  the  same  spot  on  the  skin.  This  is  essential  for,  if  the  pressure  is  relaxed 
enough  to  allow  the  fingers  to  slip  over  the  abdominal  surface,  no  deep  ef- 
fect can  be  obtained.  The  skin  is  freely  movable  over  the  deeper  structures  of 
the  abdominal  wall,  and  one  point  can  easily  be  carried  through  the  small 
circle  described.  In  some  cases,  where  the  abdominal  wall  is  very  thin  and 
lax,  the  whole  thickness  of  the  wall  may  follow  the  fingers  to  some  extent. 
The  vaginal  fingers  are  not  moved  in  the  least.  They  remain  perfectly  station- 
ary, being  required  only  to  elevate  the  infiltrated  area  so  that  it  can  be  sub- 
jected to  compression  by  the  fingers  above.  The  application  of  this  sweep- 
ing pressure,  as  just  described,  constitutes  that  other  important  manipulation 
of  massage  known  as  kneading'. 

These  two  manipulations,  stretching  and  kneading  of  shortened  and  in- 
filtrated tissues  or  of  adhesions,  constitute  the  essentials  of  pelvic  massage  in 
ordinary  cases.  "Whether  the  infiltrated  area  or  the  tense  band  is  at  the 
lower  part  of  the  broad  ligament  or  the  upper  part,  whether  it  binds  the  uterus 
backward  or  forward  or  laterally  or  holds  an  ovary  or  tube  in  abnormal  posi- 
tion, the  principles  of  manipulation  are  the  same,  namely,  to  stretch  the  adhe- 
sions or  shortened  tissues  and  to  work  the  lymph  and  venous  blood  out  of 
them  towards  the  pelvic  wall.  The  clothing  must  be  well  loosened  so  that  there 
is  no  constriction  forcing  the  intestines  into  the  pelvis.  The  bladder  and 
rectum  should  be  empty — therefore  direct  the  patient  to  take  an  enema  an 
hour  or  two  before  coming  for  treatment  and  to  empty  the  bladder  just  before 
treatment. 

The  manipulations  must  always  be  gentle  at  first,  gradually  increasing  in 
force  as  the  tenderness  diminishes.  Painful  points  should  not  be  passed  over 
directly  or  carelessly  but  circled  about  and  approached  gradually. 

As  to  the  length  of  the  seance  and  the  frequency  of  repetition,  the  physi- 
cian is  guided  by  the  conditions  present  and  the  effect  produced.  The  idea 
is  to  stretch  the  tissues  and  remove  infiltration  as  quickly  as  possible,  but  if 
too  much  force  is  used  or  the  seance  made  too  long  the  resulting  irritation 
may  increase  rather  than  diminish  the  infiltration.  The  treatments  should  be 
far  enough  separated  so  that  the  irritation  from  one,  as  evidenced  by  pain  and 
soreness,  has  largely  subsided  before  the  next  is  given.  This,  of  course,  will 
vary  much  in  different  cases.  A  seance  of  five  or  ten  minutes  repeated  from 
every  second  day  to  every  other  Aveek,  are  about  the  requirements.  The  cases 
must  be  carefully  selected,  and  if  no  decided  benefit  is  apparent  after  a  few 
treatments,   they   are   stopped  and  more   effective  measures   employed.     Of 


408  GYXECOLOGIC    TREATMENT 

course,  other  measures  are  to  be  used  iu  conjunction  with  this  treatment  as  in- 
dicated— general  measures,  internal  treatment,  hot  vaginal  douches,  pessaries, 
etc. 

Indications  for  Pelvic  Massage 

Pelvic  massage  is  of  benefit  principally  in  cases  of  uterine  displacement 
accompanied  by  the  sequelae  of  a  pelvic  cellulitis  (real  parametritis)  or  by 
old  peritoneal  adhesions  without  active  pelvic  inflammation.  It  is  useful  also 
in  some  cases  of  the  same  connective  tissue  or  peritoneal  inflammatory  sequelae 
without  important  displacement  of  the  uterus,  the  improvement  in  these  cases 
the  tissues,  the  relief  from  pressure  of  constricting  peritoneal  bands  and  the 
being  due  probably  to  the  removal  of  cellular  infiltration  and  stasis  edema  of 
improvement  of  the  lymph  and  blood  circulation  in  the  pelvis.  It  is  useful  also  in 
exceptional  cases  of  a  persistent  large  mass  of  exudate,  but  only  where  all 
active  inflammation  has  disappeared  and  nature  has  failed  to  make  the  usual 
prompt  removal  of  exudate  when  it  is  no  longer  needed  for  limiting  purposes. 
Inflammation  of  the  connective  tissue  in  this  region,  as  in  other  regions, 
runs  its  course  rather  rapidly,  ending  in  resolution  or  in  the  formation  of  an 
abscess  which  is  opened  or  opens  itself.  In  either  case  the  active  inflammation 
soon  subsides,  leaving  no  persistent  focus  of  active  inflammation,  but  only  the 
sequelae,  consisting  principally  of  scar  tissue  and  cellular  infiltration  and  the 
circulatory  disturbance  of  lymph  and  blood  resulting  therefrom.  These  are 
just  the  conditions  most  susceptible  to  improvement  by  massage.  Further- 
more, in  this  condition  comparatively  little  can  be  accomplished  by  operative 
work.  There  is  no  focus  of  persistent  inflammation  to  be  excised,  no  intra- 
peritoneal mass  of  exudate  to  be  removed,  no  intraperitoneal  bands  to  be 
broken.  The  cellular  infiltration  and  the  bands  of  scar-tissue  lie  under  the 
peritoneum  among  important  vessels  and  nerves  and  other  structures,  and  are 
of  such  nature  and  so  situated,  that  their  excision  is  not,  ordinarily,  desirable 
nor  pi'acticable. 

Allied  to  these  cases,  as  regards  their  suitableness  for  massage,  are  the 
cases  of  retrodisplacement  without  infection  in  which  the  persistence   of  the 
displacement  seems  to  be  due,  to  considerable  extent  at  least,  to  a  shortening 
of  the  upper  posterior  part  of  the  broad  ligament.     This  is  found  in  certain 
troublesome  cases  of  retrodisplacement  in  women  who  have  never  been  preg- 
nant.   It  constitutes  the  cause  of  failure  in  some  cases  submitted  to  the  ordi- 
nary operative  procedures  for  retrodisplacement.     It  is  not  effected  by  such 
measures  unless  the  involved  tissues  are  directly  divided   or  over-stretched 
at  the  time,  and  this  must  be  done  carefully  or  important  structures  Avill  be 
injured.     In   some  cases  this   contraction   is   hardly   appreciable   during   the 
•  operative  work,  the  uterus  coming  forward  without  much  resistance,  but  the 
constant  slight  pull  maintained  by  this  tense  tissue  is  sufficient  to  gradually 
draw  the  uterus  back  again  into  retrodisplacement.     In  cases  of  retrodisplace- 
ment, the  intrapelvic  conditions  should  be  carefully  studied  by  bimanual  ex- 


PELVIC    MASSAGE  409 

animation,  to  determine  just  what  holds  the  uterus  backward  or  what  causes 
it  to  go  backward  after  replacement. 

On  the  other  hand,  when  an  infectious  process  attacks  the  Fallopian  tubes 
there  is  liable  to  remain  a  focus  of  persistent  inflammation,  the  same  as  there 
does  in  the  appendix.  It  may  be  walled  otf  so  as  to  remain  in  a  measure  quies- 
cent for  weeks  or  months  at  a  time,  but  every  once  in  a  while  it  is  stirred  up 
by  extra  exertion  or  some  other  circumstance  that  increases  the  local  irritation 
or  diminishes  the  local  resistance.  It  is  evident  that  in  such  a  condition  (sal- 
pingitis), stretching  or  kneading  of  the  involved  tissue  would  only  cause  an 
increase  of  the  inflammation  and  of  the  resulting  exudate  and  disturbance. 
The  proper  treatment  in  such  a  case  is  to  remove  the  focus  of  persistent  in- 
flammation, and  this  is  accomplished  by  the  removal  of  the  diseased  tube  or 
ovary  and,  as  far  as  practicable,  of  the  accompanying  peritoneal  exudate. 

Just  a  word  as  to  the  term  ''parametritis,"  for  it  looms  up  large  in  nearly 
all  articles  on  pelvic  massage.  The  connective  tissue  al^out  the  uterus  and 
extending  out  into  the  broad  ligaments  and  sacro-uterine  ligaments,  is  often 
spoken  of  collectively  as  the  "parametrium" — a  very  convenient  term,  for  it 
is  much  shorter  than  "pelvic  connective  tissue"  or  "periuterine  connective 
tissue,"  with  which  it  is  synonymous.  Inflammation  of  the  connective  tissue 
about  the  uterus  (pelvic  cellulitis)  is  often  spoken  of  as  "parametritis."  So 
far  so  good,  for  this  also  is  a  convenient  term,  but  with  its  extended  use,  con- 
fusion has  crept  in.  In  the  first  place,  it  is  very  similar  in  sound  and  appear- 
ance to  the  term  "perimetritis,"  Avhich  means  inflammation  of  the  tissues 
around  the  uterus,  more  especially,  however,  of  the  peritoneum  and  adnexa 
(tubes  and  ovaries).  So,  even  with  a  perfectly  clear  idea  of  the  limitation  of 
parametritis,  it  may  be  confounded  by  the  hearer  or  reader  with  the  very 
similar  sounding  and  appearing  word  "perimetritis,"  which  means  almost  the 
opposite.  In  the  second  place,  the  term  parametritis  is  used  loosely  by  some 
writers  and  speakers,  which  has  led  to  ambiguity  and  much  difference  of  opin- 
ion as  to  the  efficiency  of  pelvic  massage  and  other  methods  of  treatment  in 
pelvic  inflammatory  troubles.  There  seems  to  be  a  tendency  to  apply  the 
term  parametritis  to  every  thickening  or  induration  around  the  uterus.  This 
is  inexact  and  leads  to  misunderstanding  and  confusion.  If  persisted  in  to 
any  great  extent,  it  will  necessitate  the  dropping  of  this  very  useful  and  con- 
venient term.  In  speaking  to  his  classes,  the  author  usually  employs  the  less 
convenient  term  "pelvic  cellulitis,"  because  only  one  meaning  can  be  attached 
to  it. 

In  regard  to  pelvic  massage,  so  much  has  been  claimed  for  it  and  on  the 
other  hand  so  much  has  been  said  against  it,  that  the  beginner  is  very  liable 
to  be  misled  by  one-sided  reading  or  confused  by  the  vigorous  promulgation 
of  conflicting  vicAvs.  The  markedly  denunciatory  statements  indulged  in  on 
each  side  are  in  many  cases  the  result  of  one-sided  experience.  One  physician 
prefers  operative  treatment,  uses  it  exclusively  and  denounces  massage,  about 
which  he  knows  little  or  nothing.     Another  physician  favors  massage,  uses  it 


410  GYNECOLOGIC    TREATMENT 

exclusively  and  denounces  operative  treatment,  about  which  he  knows  little 
or  nothing.  Of  course,  such  a  state  of  affairs  should  not  exist,  but  the  fact 
remains  that  it  does  exist,  not  only  in  regard  to  this  subject  but  also  in  regard 
to  other  important  subjects.  It  is  so  flattering  to  one's  vanity  to  give  a 
sweeping  opinion  on  a  subject  of  importance  and  so  easy  to  find  auditors,  that 
many  persons  make  broad  statements  without  proper  thought  and  investiga- 
tion. Such  opinions  are,  of  course,  worthless,  but  the  fact  that  they  are  worth- 
less is  often  not  known  to  those  who  hear  and  read  them,  and  the  situation  is 
thus  complicated  and  the  truth  obscured.  Differences  of  results  and  conse- 
quently differences  of  opinion  will  always  exist  on  account  of  differences  in 
physicians  and  patients,  but  we  should  always  be  ready  to  consider  a  subject  in  a 
rational  way  and  without  prejudice.  Persons  and  conditions  vary  so  much 
and  there  are  so  many  sources  of  error  that  we  must  advance  cautiously  from 
the  well  established  to  the  comparatively  unknown.  When,  however,  a  method 
of  treatment  is,  from  its  demonstrated  effect,  rationally  applicable  to  a  known 
pathologic  condition,  and  hundreds  of  thoroughly  reliable  physicians  in 
various  parts  of  the  world  have  secured  good  results  by  practical  application 
of  the  method,  there  is  no  reason  why  it  should  not  be  used  where  the  neces- 
sary skill  and  discrimination  can  be  obtained.  A  method  is  not  condemned 
because  some  have  employed  it  as  a  cure-all,  when  in  fact  it  is  applicable  to 
only  a  small  proportion  of  the  conditions  met  with,  or  because  some  have  used 
it  in  conditions  where  it  was  contraindicated  and  have  thereby  done  harm,  or 
because  some  who  were  unworthy  the  name  of  physician  have  used  it  as  a 
cloak  for  criminal  practices,  just  as  the  same  or  similar  creatures  have  used 
other  well-established  therapeutic  measures. 

Pelvic  massage  has  its  strict  indications  and  contraindications,  just  as 
has  every  other  therapeutic  measure.  Its  application  requires  much  discrim- 
ination in  the  selection  of  cases  and  much  skill  in  the  pelvic  manipulations  and 
then  a  large  fund  of  patience  and  perseverence.  Used  with  skill  and  care  in 
conjunction  with  the  other  measures,  it  has,  in  certain  conditions  already  indi- 
cated, restored  the  patient  from  a  condition  of  chronic  invalidism  to  health, 
and  to  a  condition  much  nearer  anatomic  and  physiologic  cure  than  could 
have  been  secured  by  a  cutting  operation.  In  other  eases  the  patient  is  not 
cured,  but  the  intrapelvic  condition  is  so  far  improved  that  she  is  made  fairly 
comfortable  and  able  to  get  along.  In  still  other  cases  it  does  no  good  and  is 
a  waste  of  time,  and  serves  to  postpone  the  employment  of  measures  that 
would  be  effective  in  restoring  the  patient's  health. 

Contraindications  to  Pelvic  Massage 

When  there  is  marked  tenderness  or  where  there  is  marked  hyperesthesia 
of  the  pelvic  organs  or  of  the  vagina  or  of  the  external  genitals,  pelvic  massage 
is  contraindicated.    It  is  contraindicated  also  in  the  presence  of : 


PRESSURE    TREATMENT  411 

Acute  inflammation. 
A  collection  of  pus. 
Active  salpingitis. 
Pelvic  tuberculosis. 
Malignant  disease. 
Pregnancy. 

PRESSURE  TREATMENT 

The  effects  sought  by  pressure  treatment  are  (a)  to  hasten  the  absorp- 
tion of  a  chronic  exudate  in  the  pelvis,  (b)  to  assist  in  stretching  adhesions  or 
infiltrated  tissues  and  (c)  to  assist  in  raising  a  displaced  uterus. 

The  articles  required  are  (a)  two  strong  colpeurynters  connected  by  a 
stopcock,  (b)  two  pounds  of  mercury,  (c)  bag  of  fine  shot  weighing  three 
pounds,  with  an  elastic  bandage  for  fastening  same  to  the  lower  abdomen. 
The  empty  colpeurynter  is  introduced  into  the  A^agnia,  the  patient's  hips  ele- 
vated, the  shot-bag  applied  to  the  lower  abdomen,  and  the  mercury  run  into 
the  vaginal  colpeurynter  in  sufficient  quantity  to  make  the  desired  pressure. 

Details  of  Application 

The  bladder  and  rectum  must  be  empty.  With  the  patient  in  the  dorsal 
posture  on  a  bed  or  table,  one  colpeurynter  (detached  from  the  other  and 
empty)  is  cleansed,  lubricated,  folded,  grasped  with  a  uterine  dressing  forceps 
and  introduced  to  that  portion  of  the  vaginal  vault  nearest  the  exudate.  The 
patient  then  takes  the  position  to  be  maintained  during  the  treatment — on  her 
back,  if  the  exudate  is  behind  the  uterus,  or  on  the  side  corresponding  to  the 
exudate  if  it  is  on  one  side  of  the  uterus — and  the  shot-bag  is  placed  on  the 
lower  abdomen  and  so  fastened  by  a  bandage  or  elastic  belt  that  it  will  main- 
tain the  counterpressure  in  the  direction  of  the  exudate  when  the  patient's 
hips  are  elevated.  The  foot  of  the  bed  is  then  raised  about  eighteen  inches 
and  the  hips  are  still  further  elevated  by  one  or  two  folded  pillows  placed 
under  them.  The  other  colpeurynter,  containing  the  two  pounds  of  mercury, 
is  connected  with  the  colpeurynter  tube  extending  out  of  the  vagina  and  the 
stopcock  is  opened  sufficiently  to  permit  a  small  stream  of  mercury  to  flow 
into  the  vaginal  colpeurynter  at  the  vaginal  vault.  From  one  to  two  pounds 
of  mercury  is  allowed  to  flow  into  the  vaginal  colpeurynter,  depending  on  the 
absence  of  pain.     There  should  not  be  enough  pressure  to  cause  much  pain. 

The  treatments  are  given  daily  and  at  first  should  not  last  more  than 
half  an  hour,  to  be  soon  increased  to  one  hour.  Later,  if  well  borne,  the 
treatment  may  be  kept  up  for  several  hours  at  a  time — in  fact,  may  be  con- 
tinued the  greater  part  of  the  day  with  intervals  of  rest. 

Indications  and  Contraindications 

Indications.  Pressure  treatment  is  applicable  principally  in  cases  of  ad- 
herent retrodisplaeement  of  the  uterus  and  in  cases  of  chronic  pelvic  inflam- 


412  GYNECOLOGIC    TREATMENT 

matioii  in  which  the  exudate  is  in  the  cul-de-sac  of  Douglas  or  in  the  broad 
ligament  or  in  which  there  are  adhesions  Ioav  in  the  pelvis. 

Contraindications.  When  the  exudate  is  situated  high,  above  the  fundus 
uteri  or  about  the  tubes,  this  treatment  is  not  satisfactory. 

When  severe  pain  is  caused  by  the  pressure,  the  treatment  must  be  dis- 
continued, as  there  is  danger  of  starting  up  active  inflammation  or  disseminat- 
ing an  unrecognized  focus  of  active  infection.  It  is  contraindicated  also  in 
the  presence  of: 

Acute  inflammation. 

A  collection  of  pus. 

Active  salpingitis. 

Pelvic  tuberculosis. 

Malignant  disease. 

Pregnancy. 

APPLICATIONS  TO  BODY  GENERALLY 

BATHING 

Eegular  bathing  for  hygienic  purposes  is  necessary  to  keep  the  patient  in 
good  general  health.  Also  hot  baths  or  cold  baths  may  be  required  for  their 
special  effect  on  the  patient's  nervous  system. 

The  hydrotherapeutic  methods  particularly  useful  in  gynecologic  cases 
(vaginal  douches,  moist  applications  to  lower  abdomen,  sitz-baths)  have  al- 
ready been  described. 

FRICTION  RUBBING 

Friction  rubbing  of  the  general  body  surface  with  alcohol  or  salt  or  a 
brush  or  a  rough  towel,  which  the  neurologists  have  found  so  extremely  use- 
ful in  atonic  conditions  of  the  nervous  system  and  of  the  body  generally,  is 
often  indicated  in  gynecologic  cases.  The  fact  that  the  patient  is  under 
treatment  for  some  pelvic  disease  should  not  prevent  her  receiving  such  other 
treatment  as  is  necessary.  After  operation  for  pelvic  disease  which  has  caused 
marked  deterioration  of  the  general  health,  it  is  important  to  employ  general 
measures  in  conjunction  with  the  local  measures  in  order  to  complete  the  res- 
toration to  health. 

The  detailed  consideration  of  these  various  general  measures  would'  take 
up  too  much  room  and  would  be  somewhat  out  of  place  in  a  work  of  this 
character.  The  author  must  content  himself  with  calling  attention  to  the  im- 
portance of  their  intelligent  use  in  gynecologic  cases. 

GENERAL  MASSAGE 

General  massage  also  is  invaluable  in  the  treatment  of  certain  conditions 
of  physical  depression  caused  by  or  associated  with  pelvic  disease.     The  cases 


DRESS   CORRECTION  413 

referred  to  are  those  in  whieli  the  vital  forces  are  apparently  ''worn  out"  by 
long  suffering,  chronic  septic  absorption,  autointoxication  or  faulty  metabo- 
lism. The  object  is  to  produce  a  general  tonic  effect  upon  the  muscular,  circula- 
tory, nervous,  digestive,  respiratory  and  excretory  systems. 

General  massage,  like  other  general  measures,  belongs  to  general  medicine 
and  its  description  is  not  called  for  here. 

Pelvic  massage  has  already  been  considered. 

DRESS  CORRECTION 

It  is  not  the  author's  purpose  to  take  up  in  a  general  way  the  subject  of 
dress  as  it  relates  to  health.  He  simply  desires  to  mention  two  things  that 
have  a  bearing  on  the  treatment  of  pelvic  disease. 

1.  Constriction  at  the  Waist.  By  this  constriction  the  abdominal  contents 
are  forced  downward  towards  the  pelvis,  and  thus  the  pelvic  contents  are 
subjected  to  abnormal  pressure.  This  abnormal  pressure  interferes  with  the 
circulation  in  the  various  pelvic  organs,  causing  poor  nutrition  and  chronic 
congestion. 

This  injurious  pressure  helps  to  bring  about  the  following  abnormal  con- 
ditions. In  the  young  woman,  the  nutrition  may  be  so  interfered  with  that 
perfect  development  is  not  attained.  In  the  adult,  the  chronic  pressure  and 
congestion  tend  to  cause  chronic  endometritis,  displacements  of  the  uterus 
and  chronic  irritation  and  enlargement  of  the  ovaries.  Following  parturition, 
the  persistent  congestion  tends  to  cause  subinvolution  and  chronic  endometritis. 
In  laceration  of  the  pelvic  floor,  the  pernicious  effects  of  the  laceration  are 
much  increased  by  the  constant  strong  downward  pressure  of  the  abdominal 
contents.  In  retrodisplacements  of  the  uterus,  the  fundus  uteri  is  forced  still 
further  into  the  abnormal  position  by  this  downward  pressure  from  above,  and 
the  ovaries  also  are  forced  down  beside  the  displaced  uterus.  In  prolapse,  the 
structures  are  constantly  forced  further  and  further  out  of  the  pelvis  and,  in 
addition,  there  is  caused  a  general  splanchnoptosis.  This  tendency  of  waist 
constriction  to  cause  permanent  displacement  of  various  abdominal  organs, 
adds  many  abdominal  symptoms  to  those  of  the  pelvic  disturbance. 

2.  Dragging-  Weight  at  the  Waist  Line.  To  support  heavy  skirts  by  means 
of  a  string  tied  around  the  waist  is  fully  as  injurious  as  the  wearing  of  the 
average  corset.  The  heavy  skirts  drag  down  the  abdominal  organs  towards 
the  pelvis  and  produce  injurious  pressure  on  the  pelvic  organs. 

To  prevent  these  injurious  effects,  all  constriction  should  be  removed 
from  about  the  waist  and  the  clothing  should  be  supported  from  the  shoulders, 
as  has  been  insisted  upon  so  strongly  by  those  who  have  given  much  careful 
study  to  the  relation  of  the  clothing  to  bodily  health,  strength  and  beauty. 
This  is  advisable  in  well  persons,  but  is  imperatively  important  in  those  suf- 
fering with  pelvic  disorders.  Any  "corset"  or  ''support"  or  "stay"  that  is 
used,  should  make  no  firm  constriction  above  the  iliac  crests.     Some  are  so 


414  GYNECOLOGIC    TEEATMENT 

arranged  that  they  not  only  cause  no  waist  constriction,  but  really  give  some 
support  to  the  lower  abdomen  and  hence  are  beneficial  in  cases  requiring 
support. 

POSTURAL  METHODS  AND  EXERCISE 

KNEE-CHEST  POSTURE 

The  patient  supports  herself  on  the  knees  and  chest   (Fig.  444).     The 
head  rests  on  a  pillow,  with  the  face  turned  to  one  side,  and  the  breasts  are 


Fig.   444.   The     Knee-chest     Posture.       The     thighs     should     be     perpendicular     and     the     breasts     should    be 
brought  against  the  table.      All   constriction   about  the  waist   must   be    removed. 

brought  as  closely  as  possible  against  the  table.  The  clothing  must  be  well 
loosened  about  the  abdomen.  The  thighs  should  be  vertical.  Unless  particular 
attention  is  given  to  the  latter  point  the  patient's  hips  will  be  too  far  for- 
ward or  too  far  backward,  thus  losing  a  large  part  of  the  desired  elevation. 
This  position  may  be  maintained  from  one  to  ten  minutes. 

The  effect  of  this  posture  is  to  temporarily  take  all  downward  pressure  off 
the  pelvic  organs  and  permit  them  to  gravitate  toward  the  abdominal  cavity 
(Fig.  445).    The  downward  pressure  on  the  pelvic  organs  is  for  the  time  being 


KNEE-CHEST   POSTURE 


415 


relieved,  the  local  circulation  is  greatly  improved  and  a  movable  retrodisplaeed 
fundus  uteri  tends  to  gravitate  forward  towards  the  normal  position.  The  ef- 
fect is  much  increased  if  the  vagina  be  opened  with  a  speculum  or  with  the 
fingers  so  that  air  may  enter. 


Fig.  445.     The    Knee-chest    Posture,    showing   the    pelvic    structures    in    outline    and    illustrating    the    tend- 
ency of  the  uterus  and  adnexa  to  gravitate  forward.      (Montgomery — Practical  Gynecology.) 


Fig.  446.     The  Knee-chest  Posture,    with   the   patient   draped   ready   for  packing   or   other   treatment. 


416  GYNECOLOGIC    TREAT:\IEXT 

Indications  for  Knee-Chest  Posture 

The  knee-cliest  posture  is  used  in  office  treatment  for  the  following  pur- 
poses: 

To  assist  in  replacing  an  ordinary  movable  retrodisplaeed  uterus. 

To  assist  in  replacing  a  pregnant  retrodisplaeed  uterus. 

To  assist  in  pushing  a  tumor,  impacted  in  the  pelvis,  back  into  the  ab- 
dominal cavity. 

To  assist  in  replacing  a  vaginal  hernia. 

To  hold  the  uterus  as  near  as  possible  to  normal  position  while  introduc- 
ing a  vaginal  tamponade,  for  retrodisplacement  or  for  prolapse. 

Fig.  446  shows  the  patient  in  the  knee-chest  posture  and  draped  with  the 
sheet  for  treatment. 

The  knee-chest  posture  is  used  by  the  patient  at  home  as  an  aid  in  the 
treatment  of  the  following  conditions : 

Eetrodisplacement,  especially  when  the  uterus  can  not  be  entirely  replaced 
or  shows  a  tendency  to  return  to  the  backward  position. 

Downward  displacement  of  the  pelvic  organs,  from  laceration  of  the  pel- 
vic floor  or  from  beginning  prolapse  or  from  simple  relaxation  and  in- 
traabdominal pressure. 

The  venous  congestion  and  consequent  heaviness  of  the  organs  is  for  the 
time  being  relieved  and  the  beneficial  effect  is  sometimes  noticed  for  hours 
afterward.  The  patient  is  directed  to  take  the  posture  ordinarily  for  one  or 
two  minutes  twice  daily.  Usually  the  most  convenient  time  is  while  in  bed. 
just  after  retiring  in  the  evening  and  just  before  rising  in  the  morning.  Used 
for  two  or  three  months  after  labor,  this  is  exceedingly  useful  in  preventing 
retrodisplacement  of  the  uterus. 

TRENDELENBURG  POSTURE 

In  the  Trende]en])urg  posture  the  hips  are  elevated.  The  elevation  of  the 
hips  may  be  moderate  or  extreme,  as  required  by  the  particular  case.  This  pos- 
ture is  used  principally  in  operative  work,  though  it  is  sometimes  useful  in 
diagnosis  and  in  minor  gynecologic  treatment.  It  is  employed  in  the  pressure- 
weight  treatment  previously  described,  in  pelvic  massage  in  certain  cases  where 
it  is  important  to  get  the  intestines  out  of  the  pelvis,  and  also  in  eases  where 
it  is  desired  to  employ  gravity  in  moving  an  abdominal  or  pelvic  organ  upward 
towards  the  abdominal  cavity  but  in  which  the  patient  can  not  take  the  knee- 
chest  posture. 

EXERCISE 

General  Exercise.  Exercise  in  the  form  of  walking,  horse-back  riding, 
driving,  outdoor  games  and  general  gymnastic  movements  (both  outdoors  and 
indoors)  may  be  required  in  patients  presenting  pelvic  disturbance  depending 


INTERNAL    TREATMENT  417 

Oil  depression  of  the  general  health,  particularly  in  certain  forms  of  amenor- 
rhea. These  measures  are  used,  however,  almost  exclusively  for  their  effect 
on  the  general  health,  and  the  description  of  the  details  of  their  application 
belongs  to  general  medicine. 

Special  Exercise.  There  is  one  useful  and  simple  procedure  that  is  particu- 
larly applicable  to  certain  gynecologic  patients.  The  author  refers  to  volun- 
tary contraction  of  the  muscles  of  the  abdominal  wall.  This  is  one  of  the 
most  effective  measures  that  can  be  employed  in  the  treatment  of  that  affec- 
tion which  is  so  distressing  to  many  women,  namely,  prominence  of  the  abdo- 
men from  relaxation  of  the  wall.  This  is  seen  principally  following  confine- 
ment, the  overstretched  abdominal  muscles  (overstretched  from  the  preg- 
nancy) having  never  regained  their  tone. 

The  exercise  consists  in  the  patient  raising  the  head  and  shoulders  while 
she  is  lying  on  her  back.  The  arms  should  be  crossed  over  the  chest  and  the 
head  and  shoulders  raised  by  the  abdominal  muscles  alone.  Once  or  twice 
daily  the  patient  goes  through  this  exercise,  raising  the  shoulders  ten  to 
twenty  times  at  each  exercise.  As  the  recti  muscles  become  strong,  the  move- 
ment may  be  varied  somewhat  to  the  side  in  order  to  bring  into  action  the 
lateral  abdominal  muscles. 

INTERNAL  TREATMENT 

Internal  treatment  may  be  in  the  form  of  medicines  or  of  diet  or  of 
psycho-therapy. 

MEDICINES 

Internal  medication  affects  pelvic  lesions  principally  in  an  indirect  way — 
by  improving  the  quality  of  the  blood  supplied  to  the  pelvic  organs,  by  reliev- 
ing congestion  and  bettering  the  pelvic  circulation,  by  toning  up  the  nervous 
system,  etc.  These  indirect  effects,  however,  are  often  of  decisive  importance. 
(See  Chapter  xv.) 

The  author  wishes  here  to  call  attention  to  certain  classes  of  internal 
remedies  that  are  often  indicated  in  the  treatment  of  patients  with  pelvic 
disease. 

1.  Uterine  Astringents.  To  this  class  belong  ergot,  pituitrin,  stypticin  and 
hydrastis.  Ergot  and  pituitrin  cause  contraction  of  involuntary  muscular  tis- 
sue. The  uterus  is  composed  principally  of  such  tissue,  consequently  ergot  and 
allied  substances  have  a  marked  tonic  effect  on  the  uterine  wall.  The  relaxed 
and  dilated  uterine  blood  vessels  are  narrowed,  the  chronic  congestion  is  re- 
lieved and  the  tendency  to  inflammatory  infiltration  diminished. 

This  class  of  remedies  is  beneficial  in  all  conditions  of  chronic  uterine  con- 
gestion and  hemorrhagic  tendency,  except  those  connected  with  pregnancy. 

2.  Laxatives.    It  is  difficult  to  appreciate  the  full  value  of  laxatives  in  the 


418  GYNECOLOGIC    TREAT^IEXT 

treatment  of  patients  with  pelvic  disease  until  the  marked  benefit  due  to  them 
becomes  a  matter  of  personal  observation  through  years  of  experience.  The  in- 
telligent and  systematic  use  of  saline  purgatives  in  acute  inflammatory  condi- 
tions and  of  the  milder  laxatives  (cascara  sagrada,  etc.)  in  chronic  pelvic  dis- 
eases is  one  of  the  greatest  aids  in  restoring  the  organs  to  their  normal  condi- 
tion, where  such  restoration  can  be  accomplished  by  minor  measures,  and  in 
preparing  the  structures  for  successful  operative  work  in  the  cases  where 
operation  is  necessary.  A  constantly  loaded  rectum  and  colon  chokes  the  pel- 
vis mechanically,  causes  chronic  pelvic  congestion,  both  l)y  direct  pressure  and 
by  irritation  and  also  by  contributing  to  an  atonic  conditon  of  the  pelvic  tis- 
sues, and  depresses  the  general  health  by  autointoxication  from  the  intestinal 
contents. 

3.  Sedatives.  In  various  conditions  sedatives  are  required,  either  on  ac- 
count of  local  pain  or  because  of  marked  general  nervousness.  In  ordinary  pelvic 
distress,  consisting  of  a  mixture  of  pain  and  pressure  and  fullness,  the  prepara- 
tions containing  viburnum  prunifolium  usually  give  some  relief.  If  there  is 
simply  general  nervousness  and  sleeplessness,  sodium  bromide  is  effective.  If 
there  is  associated  bladder  irritability,  hyoscyamus  in  combination  with  potas- 
sium citrate  or  other  alkaline  tends  to  lessen  the  vesical  tenesmus.  When  there 
is  severe  pain,  stronger  analgesics  are  required,  for  example,  codeine  in  com- 
bination with  phenacetin,  and  if  there  is  still  no  relief  it  may  be  necessary  to 
give  morphine.  The  latter,  when  given  at  all.  should  be  given  in  such  form 
that  the  patient  does  not  know  what  she  is  taking.  For  that  reason  it  is  prefer- 
able to  give  it  in  a  capsule  in  combination  with  some  indifferent  substance 
rather  than  in  the  usual  small  tablets,  the  contents  of  which  are  at  once  sur- 
mised by  most  patients. 

4.  Tonics.  Tonics  containing  iron  are,  of  course,  indicated  in  anemic  pa- 
tients, and  it  is  usually  advisable  to  give  also  some  one  or  more  of  the  gen- 
eral tonics,  such  as  strychnia,  quinine,  arsenic,  etc. 

5.  Organo-therapy.  The  use  of  animal  extracts  or  desiccated  tissue  from 
various  glands,  has  assumed  a  new  importance  as  our  knowledge  of  the  duct- 
less gland  system  has  increased.  This  important  form  of  therapy  is  considered 
in  detail  in  the  special  chapter  on  the  endocritic  glands  (Chapter  xv). 

6.  Serum  Therapy.  In  various  infective  processes  much  good  may  be  ac- 
complished by  the  injection  of  bacterial  products  which  inhibit  the  growth  of 
the  corresponding  bacteria.  The  most  striking  and  certain  effects  are  seen  in 
the  cure  of  diphtheria  by  diphtheria  antitoxin  and  the  prevention  of  tetanus  by 
antitetanic  serum. 

Antistreptococcic  serum  in  its  various  modifications  has  proved  beneficial 
in  cases  of  puerperal  infection  and  other  forms  of  streptococcus  infection  and 
of  mixed  (staphylococcus  and  streptococcus)  infection.  In  some  cases  the  ef- 
fect is  very  pronounced,  apparently  saving  the  patient's  life,  while  in  other 
cases  there  is  apparently  no  effect. 


INTERNAL    TREATMENT  419 

It  is  worthy  of  a  thorough  trial  in  severe  cases,  as  explained  under  Acute 
Pelvic  Inflammation  (see  Chapter  x). 

Bacteria  Treatment.  The  object  of  this  treatment  is  to  increase  the  de- 
struction of  invading  bacteria  by  the  white  blood  corpuscles  (leukocytes). 

The  power  of  the  leukocytes  to  take  in  and  destroy  bacteria  (phagocytosis 
has  long  been  known,  through  the  investigation  of  Metchnikoff.  Within  the 
last  few  years  much  additional  information  regarding  phagocytosis  has  been 
acquired.  Various  facts  have  been  brought  out  by  different  investigators,  but 
it  is  largely  through  the  work  of  A.  E.  Wright,  of  England,  that  the  subject 
has  been  developed  to  the  point  where  a  definite  therapeutic  method  has  re- 
sulted. 

The  essential  features  of  the  opsonic  theory  and  vaccine  treatment  may  be 
summarized  briefly  as  follows: 

a.  Leukocytes,  freed  from  the  serum  and  mixed  with  bacteria,'  have  no 
phagocytic  power.  When  blood  serum  is  added  to  the  mixture,  phagocytosis 
begins.  This  difference  is  diie  to  some  substance  in  the  serum  that  combines 
with  that  particular  class  of  bacteria,  and  prepares  the  bacteria  for  ingestion 
by  the  leukocytes.  This  is  designated  as  an  ''opsonic"  effect  (from  opsono — 
I  cater  for  or  prepare  food  for),  and  the  substance  that  thus  prepares  the  bac- 
teria is  called  an  ' '  opsonin. ' ' 

b.  The  opsonic  poAver  of  a  patient's  blood  serum,  for  the  particular  bac- 
teria causing  the  illness,  may  be  definitely  measured  by  bacteriologic  methods. 
This  is  then  compared  with  the  opsonic  power  of  the  blood  serum  of  a  normal 
individual  for  the  same  bacteria.  In  this  way  is  secured  the  "opsonic  index" 
(relative  opsonic  power)  of  the  patient's  blood. 

c.  When  the  opsonic  index  is  low  (poor  resistance  to  the  invading  bac- 
teria), it  may  be  increased  by  the  subcutaneous  injection  of  devitalized  cul- 
tures of  the  infecting  organism.  The  toxic  principle  contained  in  the  bacterial 
bodies,  when  brought  in  contact  with  the  blood  serum,  increases  the  opsonizing 
power  of  the  serum  for  that  particular  kind  of  bacteria.  Thus  the  opsonic  in- 
dex of  the  patient's  blood  may  be  raised  to  normal,  and  then  the  growth  of  the 
infecting  microorganism  is  checked  and  the  lesion  heals. 

As  more  knowledge  was  acquired  concerning  the  effects  of  this  vaccine 
treatment,  it  Avas  found  possible  to  satisfactorily  guide  the  treatment  by  the 
clinical  symptoms  instead  of  depending  on  the  opsonic  index,  the  determina- 
tion of  which  required  a  skilled  pathologist  and  a  laboratory.  This  increased 
the  field  of  employment  of  this  treatment  very  much,  and  it  is  now  extensively 
used  in  various  infections.  Another  important  step  in  extending  the  useful- 
ness of  the  vaccine  treatment  Avas  the  manufacture  and  marketing  of  stock  vac- 
cines almost  as  effective  as  autogenous  vaccines.  These  are  put  out  by  differ- 
ent reliable  firms  under  different  names,  and  this  enables  the  physician  to  use 
this  remedy  promptly,  Avithout  the  delay  and  expense  incident  to  the  manu- 


420  GYNECOLOGIC    TREATMENT 

faeture  of  autogenous  vaccine.     However,  in  particularly  resistant  cases  it  is 
well  to  fall  back  on  the  autogenous  vaccine. 

7.  Special  Medication.  In  many  patients  with  pelvic  disease  there  are  com- 
plicating or  associated  disturbances  that  require  treatment,  such  as  disease 
of  the  stomach,  liver,  lungs,  kidneys,  etc.  Care  should  be  taken  that  such 
coincident  affections  be  not  overlooked  for  they,  as  well  as  the  pelvic  lesion, 
must  receive  proper  treatment  in  order  to  restore  the  patient  to  health. 

DIET 

A  comprehension  of  the  principles  of  proper  diet  and  an  intelligent  em- 
ployment of  the  same  is  necessary  in  overcoming  malnutrition  and  in  rescuing 
patients  from  the  depraved  general  health  occasioned  by  certain  pelvic  dis- 
eases. In  this  connection,  howeA^er,  the  diet  has  to  do  primarily  with  the  gen- 
eral nutrition  and  only  remotely  with  the  pelvic  lesion.  The  principal  way  in 
which  the  details  of  diet  enter  directly  into  the  treatment  of  pelvic  lesions  is 
in  the  after-care  of  operative  eases,  consequentlj^,  such  details  of  diet  will  be 
given  in  Chapter  xvii. 

PSYCHO-THERAPY 

Many  nervous  affections  require  psycho-therapy,  such  as  competent  and 
discriminating  neurologists  are  using  more  and  more.  This  subject  has  been 
carefully  investigated  in  recent  years  by  reliable  physiologists  and  clinicians, 
and  methods  of  treatment  have  been  worked  out  which,  in  conjunction  with 
necessary  medication  or  operative  measures,  will  greatly  hasten  the  cure  in 
many  cases,  and  will  restore  to  health  some  patients  otherwise  incurable. 

OPERATIONS 

Careful  anatomic  and  pathologic  investigations  have  demonstrated 
that  many  pelvic  lesions  are  of  such  nature  and  so  situated  that  a  cure  can  be 
effected  by  nothing  short  of  operative  treatment,  with  its  direct  handling  of 
the  diseased  tissues  and  extirpation  of  the  hopelessly  damaged. 

In  some  cases  this  is  evident  from  the  very  nature  of  the  lesion,  as  in  the 
case  of  malignant  diseases  and  tumors  generally.  On  the  other  hand,  in  many 
inflammatory  lesions  the  question  as  to  whether  or  not  operative  treatment  will 
be  necessary  can  be  answered  decisively  only  after  nature,  with  the  aid  of 
minor  measures,  has  been  given  a  thorough  trial.  The  operative  measures  indi- 
cated in  the  various  affections  will  be  mentioned  in  the  appropriate  chapters. 


CHAPTER  IV 

DISEASES  OF  THE  EXTERNAL  GENITALS  AND  VAGINA 

POINTS  IN  ANATOMY 

EXTERNAL   GENITALS 

The  external  genitals  (Figs  40,  192),  called  also  the  vulva  and  the  pudenda, 
include  the  following  structures: 

Mons  Veneris. 

Labia  Majora. 

Labia  Minora. 

Clitoris. 

Vestibule. 

A^ulvo-vaginal  Glands. 

Hymen. 

The  mons  veneris  (Figs.  1,  3,  28)  is  simply  a  pad  of  subcutaneous  fat  lying 
over  the  symphysis  pubis.  The  triangular  area  which  it  forms  is  covered  with 
hair  after  puberty.  The  base  of  the  triangle  is  represented  by  a  slight  groove 
at  the  lower  limit  of  the  hj'pogastric  region,  and  the  loAver  portion  is  con- 
tinuous with  the  labia  majora.  Examination  of  a  miscroscopic  section  through 
this  region  shows  the  usual  characteristics  of  skin,  i.  e.,  many  layers  of  squa- 
mous epithelial  cells  (the  deepest  being  cubical  and  the  most  superficial  being 
flattened  and  horny)  placed  on  loose  connective  tissue,  and  presenting  hairs, 
sebaceous  glands  and  sweat  glands.  A  little  deeper  there  is  much  fat,  which 
is  penetrated  and  held  together  by  fibrous  septa  that  divide  it  into  lobules. 
There  are  also  many  elastic  fibers. 

The  labia  majora  (Figs.  40,  41,  192)  are  two  cutaneous  folds  which  extend 
one  on  either  side,  around  the  vaginal  opening.  They  are  apparently  con- 
tinuations of  the  mons  veneris  and,  passing  backward,  end  by  joining  the 
perineum.  The  external  surface  of  each  labium  ma  jus  presents  the  ordinary 
characteristics  of  integument.  Each  labium  is  limited  externally  by  the 
genito-crural  fold  and  corresponds  to  that  side  of  the  scrotum  in  the  male.  The 
round  ligament,  coming  through  the  inguinal  canal  of  each  side,  terminates 
in  the  upper  part  of  the  labium  majus  of  that  side.  Sometimes  a  distinct 
canal  remains  open  for  some  distance  along  the  round  ligament.  This  is 
kno\^ai  as  the  canal  of  Nuck,  and  through  it  a  hernia  may  take  place  into 
the  labium,  constituting  a  labial  hernia.     This  is  known  also  as  a  pudendal 

421 


422  DISEASES   OF    THE    EXTERNAL    GENITALS    AND   VAGINA 

hernia.  The  hernial  contents  may  be  intestine  or  omentum  or  ovary  or  even 
the  uterus.  Occasionally  the  canal  of  Nuck  is  shut  off  from  the  peritoneal 
cavity,  and  the  sac  thus  formed  fills  with  fluid,  giving  rise  to  pudendal  hydro- 
cele or  "hydrocele  of  the  canal  of  Nuck."  The  inner  surface  of  each  labium 
majus  is  smooth  and  of  a  pinkish  color.  It  has  largely  lost  one  of  the  char- 
acteristics of  integument — the  hairs — only  a  few  fine  hairs  being  found  here. 

In  children  the  labia  majora  are  very  small  and  the  labia  minora  project 
between  them.  As  puberty  is  approached  the  external  labia  become  larger 
and  meet  in  the  median  line.  At  puberty  they,  in  common  with  the  mons 
veneris,  become  covered  with  hair.  A  little  later  in  life,  particularly  in  mar- 
ried women,  the  labia  minora  become  enlarged  so  much  that  they  project 
forward,  separating  the  labia  majora.  In  old  age  the  labia  undergo  marked 
diminution  in  size  and  prominence,  the  shrinking  being  due  largely  to  ab- 
sorption of  the  fat. 

Microscopic  examination  of  a  section  of  a  labium  majus  shows  the  same 
structures  found  in  the  mons  veneris,  the  only  difference  being  that  on  the 
inner  surface  of  the  labium  there  are  only  a  few  hairs,  and  they  are  sni-all. 
There  are,  however,  many  sebaceous  glands.  There  are  also,  of  course,  the 
arteries,  veins  and  other  structures  found  in  cutaneous  and  subcutaneous 
tissues.  The  connective  tissue  is  rich  in  elastic  fibres,  and  still  deeper  there 
is  the  thick  deposit  of  fat  that  gives  the  labium  its  prominence.  The  veins 
are  numerous  and  large,  and  become  much  distended  when  there  is  intra- 
pelvic  pressure,  as  in  pregnancy  or  a  tumor.  Under  such  circumstances,  a 
wound  of  the  labium  may  lead  to  serious  arid  even  fatal  hemorrhage. 

The  labia  minora  (Figs.  192, 196, 197),  or  nymphae,  are  two  delicate  muco- 
cutaneous folds  lying  between  the  labia  majora,  one  on  each  side  of  the 
vaginal  opening.  Each  labium  minus  apparently  grows  from,  or  is  a  second- 
ary fold  of,  the  upper  and  inner  portion  of  the  labium  majus  of  that  side. 
In  stout  women  the  nymphae  are  normally  concealed  by  the  labia  majora. 
Ordinarily,  particularly  in  married  women,  they  project  slightly.  Frequently 
they  are  somewhat  enlarged  and  project  half  an  inch  or  more.  The  enlarge- 
ment is  usually  not  exactly  symmetrical,  and  in  some  cases  it  is  confined  to 
one  labium.  In  a  valuable  article  on  these  enlargements  of  the  labia  minora, 
Dickinson  upholds  the  idea  that  whenever  the  enlargement  is  marked  it 
is  proof  of  excessive  irritation  of  the  labium.  It  is  stated  that  among  the 
Hottentots,  owing  to  certain  treatment  practiced  in  childhood,  the  labia 
minora  often  become  excessively  developed  and  hang  like  a  thick  apron 
betAveen  the  thighs  (Fig.  249).  The  labia  minora  begin  just  below  the  ante- 
rior junction  of  the  labia  majora  as  double  folds  which  pass  above  and  below 
the  clitoris  (Fig.  197).  The  folds  that  join  above  the  clitoris  form  the  pre- 
puce of  the  same.  The  labium  minus  of  each  side  then  descends  along  the 
inner  side  of  the  labium  majus  and  blends  with'labium  majus  about  the  junc- 
tion of  the  middle  and  lower  third.  The  posterior  extremities  of  the  labia 
minora  are  united  by  a  delicate  fold  which  extends  betAveen  them  just  Avithin 


POINTS    IN    ANATOMY    OF    EXTERNAL    GENITALS  423 

the  posterior  margin  of  the  vulvar  orifice,  forming  the  fourchette.  When 
the  labia  are  separated,  the  fourchette  is  made  tense  and  between  it  and  the 
hymen  is  a  small  depression  called,  from  its  boat-like  shape,  the  ''fossa  iiavi- 
cularis."  This  delicate  fourchette  is,  except  in  rare  cases,  torn  at  childbirth, 
and  in  some  cases  is  obliterated  even  by  sexual  intercourse.  It  is  best  seen 
in  the  virgin. 

There  has  been  much  dispute  as  to  Avhether  the  inner  surfaces  of  the  labia 
minora  are  covered  by  integument  or  mucous  membrane.  The  covering  pre- 
sents some  of  the  characteristics  of  each.  It  is  a  transitional  form  of  covering 
and  represents  one  step  in  the  several  changes  Avhich  take  place  from  the 
labia  majora  to  the  external  surface  of  the  cervix.  The  outer  surfaces  of 
the  labia  majora  are  ordinary  integument.  On  the  inner  surfaces  of  the  same 
structures,  the  hairs  are  much  reduced  in  size  and  number.  On  the  labia 
minora,  the  hairs  are  absent,  though  the  sebaceous  glands  are  still  present. 
On  the  vestibule,  only  a  few  glands  remain  and  the  thinning  of  the  epithe- 
lium is  more  marked.  In  the  vagina,  all  glands  disappear  (it  being  now 
generally  held  that  there  are  no  glands  in  the  normal  vagina)  and  the  epithe- 
lium becomes  thinner  and  the  papillae  less  marked.  Over  the  vaginal  portion 
of  the  cervix  the  papillae  have  almost  disappeared.  So  there  is  a  gradual 
transition  from  ordinary  integument,  with  a  thick  epithelial  layer  and  hairs 
and  sebaceous  glands  and  sweat  glands  and  marked  papillae,  to  a  thin  epithe- 
lial layer  without  hairs  or  glands  and  almost  without  papillae.  When  the 
vaginal  wall  is  turned  out  for  a  long  time,  as  in  prolapse,  and  exposed  to 
friction  by  the  clothing,  the  epithelial  layer  becomes  much  thickened,  and  if 
the  surface  is  kept  dry  it  becomes  horny  like  the  external  integument. 

The  labia  minora  have  many  small  folds,  giving  a  very  uneven  surface. 
Examination  of  a  section  of  a  labium  minus  shows  numerous  epithelial  depres- 
sions, owing  to  the  much  folded  surface.  The  bands  and  nests  of  epithelial 
cells  seen  in  such  a  section  are  simply  oblique  cuts  of  normal  folds  and  in- 
growths. The  labia  minora  are  very  rich  in  blood  vessels,  especially  veins, 
so  much  so  that  the  structure  partakes  of  the  nature  of  erectile  tissue.  They 
are  also  rich  in  lymphatics  and  nerves. 

The  clitoris  (Figs.  1,  192,  207,  468)  is  the  analogue  of  the  penis  in  the  male, 
and  is  situated  just  below  the  anterior  junction  of  the  labia  majora.  It  is 
a  small  erectile  organ  richly  supplied  with  blood  and  nerves,  and  is  attached 
to  the  sides  of  the  pubic  arch  by  its  crura.  In  both  the  clitoris  and  the  labia 
minora  there  are  special  nerve  endings.  Examination  of  a  section  of  the 
clitoris  shoAvs  the  erectile  nature  of  the  structure.  During  sexual  excitement 
the  clitoris  fills  with  blood  and  becomes  swollen  and  firmer.  It  is  supposed 
to  be  the  most  sensitive  of  all  the  genital  organs  to  sexual  contact,  and  on  this 
account  excision  of  the  clitoris  (clitoridectomy)  was  proposed  and  carried  out 
for.  the  relief  of  disturbances  depending  on  sexual  hyperesthesia,  but  the 
results  were  not  such  as  to  recommend  the  operation,  and  it  is  now  rarely 
practiced. 


424 


DISEASES    OF    THE   EXTERNAL    GENITALS   AND   VAGINA 


The  vestibule  (Figs.  192,  197)  is  an  elliptical  area  situated  between  the 
labia  minora.  The  sides  are  formed  by  the  labia  minora,  the  anterior  end 
extends  to  the  clitoris,  and  the  posterior  end  is  formed  by  the  junction  of  the 
labia  majora.  Into  this  vestibule  four  canals  open — the  urethra,  the  vagina 
and  the  duct  of  the  vulvo-vaginal  gland  of  each  side.  The  urethral  opening, 
the  meatus  urinarius,  is  situated  just  above  the  vaginal  orifice  (Fig.  197). 
In  the  nullipara  it  is  small  and  round.  In  the  multipara  it  is  larger  and 
somewhat  star-shaped,  and  there  is  often  some  pouting  or  projection  of  the 
urethral  mucosa.  This  change  is  due  to  the  swelling  and  distortion  during 
labor,  from  which  the  parts  never  return  absolutely  to  their  former  condition. 
The  floor  of  the  vestibule  is  formed  of  several  layers  of  squamous  epithelium 
and  under  this  the  subepithelial  connective  tissue.  There  are  a  few  glands, 
some  of  which  at  times  become  enlarged. 

The  MEATUS  URINARIUS,  as  well  as  the  urethra,  is  lined  with  stratified  squa- 


r  . 

»• 

i 

i 

A 

X' 

'T.'       . 

■^ 

HP 

Fig.  447.  Indicating  the  line  of  division  of  che 
urethra  to  give  the  view  shown  in  Fig.  448.  (Dud- 
ley— Practice   of    Gynecology.) 


Fig.  448.  The  Urethra  divided  so  as  to  show 
the  openings  of  Skene's  glands.  The  openings  are 
situated  just  within  the  meatus,  one  on  either  side. 
(Dudley.) 


mous  epithelium  on  a  basis  of  connective  tissue  rich  in  cells.  This  connective 
tissue  of  the  meatus  and  the  urethra  presents  usually  many  typical  lymph- 
modules  of  microscopic  size.  Just  Avithin  the  meatus,  near  the  posterior  wall, 
are  the  openings  of  two  diverticula,  one  on  either  side.  They  are  known  as 
Skene's  ducts  or  Skene's  glands.  They  are  called  also /'periurethral  ducts." 
Their  size  and  shape  and  location  are  shown  in  Figs.  447,  448,  449  and  450. 
They  are  important  in  that  gonorrheal  infection  may  extend  into  them  and 
persist  there  indefinitely.  Just  back  of  the  lining  of  the  vestibule  there  are 
two  masses  of  veins,  one  on  either  side  of  the  vaginal  orifice,  called  the  bulbs 


POINTS    IN    ANATOMY    OF    EXTERNAL    GENITALS 


425 


of  the  vestibule  (Fig.  451).  The  bulbi  vestibuli  lie  just  in  front  of  the  anterior 
layer  of  the  triangular  ligament.  They  are  supposed  to  correspond  to  the 
corpus  spongiosum  of  the  male.  In  wounds  of  this  region,  or  in  operations, 
if  these  vascular  bulbs  are  injured  there  is  troublesome  bleeding. 

The  viilvo-vaginal  glands  are  two  glands  situated  beside  the  vaginal  en- 
trance, one  on  either  side  (Fig.  45).  They  correspond  to  CoAvper's  glands  in 
the  male,  though  their  relations  to  the  triangular  ligament  is  not  so  clearly 
defined,  apparently  varying  some  in  different  cases.  They  lie,  as  a  rule, 
liehind  the  anterior  layer  of  the  ligament,  and  may  lie  behind  or  in  front  of 
the  posterior  layer.  Each  gland  lies  very  close  to  the  lower  end  of  the  venous 
l)ulb  of  that  side.  The  gland  is  a  small  reddish  body  about  the  size  of  a  bean, 
and  belongs  to  the  racemose  variety  of  glands.  Its  secretion  is  discharged 
through  a  small  duct  which  opens  just  in  front  of  the  hymen,  about  the  junc- 


'1 


Fig.  449.  Cross  section  of  the  Urethra,  show- 
ing the  periurethral  ducts  (Skene's  glands).  U. 
Urethra.  A.  Periurethral  ducts.  (Dudley — Prac- 
tice of  Gynecology.) 


Fig.  450.  This  gives  a  clear  idea  of  the  size 
and  relation  of  the  periurethral  ducts  (Skene's 
glands).  The  floor  of  the  urethra  has  been  divided 
longitudinally,  the  end  of  the  urethra  raised  and  a 
probe  introduced  into  each  of  the  periurethral  ducts. 
(Skene — Diseases  of   Women.) 


tion  of  the  lowei-  with  the  middle  third  of  the  side  of  the  vaginal  orifice.  When 
the  gland  is  normal,  this  opening  has  to  be  looked  for  rather  carefully  to  be 
seen.  AYhen  the  gland  has  once  become  inflamed,  the  opening  is  easily  seen, 
for  it  is  larger  and  is  usually  surrounded  by  a  small  reddened  area.  The 
mucous  secretion  of  the  gland  acts  as  a  simple  lubricant  to  the  parts  and  is 
discharged  during  sexual  excitement.  When  inflamed,  the  gland  is  felt  as  a 
hard  tender  mass  beside  the  vaginal  opening  (Fig.  47). 

The  hymen  (Figs.  192,  193)  is  a  circular  or  crescentic  fold  of  mucosa  and 
submucous  connective  tissue,  situated  at  the  vaginal  entrance  and  partially 
closing  the  same  (Fig.  192).     The  shape  of  the  hymen  and  the  opening  in  it 


426 


DISEASES    OF    THE   EXTERXAI.    GENITALS    AND   VAGINA 


Fig.   451.     The  \'eins   of  the   External   Genitals,  including  the   "bulb  of  the  vestibule,"   on   the  left  side.      V. 
\'agina.     ]\I.   Meatus.     /.   Left  venous   "bulb."      (Savage — Anatomy   of  Pelvic   Organs.) 


Fig.   452.     The    Arteries    and    Nerves    of   the    external    genitals.      (Savage — Anatomy    of   Pelvic   Organs.) 


POINTS    IN    ANATOMY    OF    VAGINA  ^  427 

vary  much  in  different  persons.  Fig.  193  shows  several  forms.  The  cres- 
centic  hymen  and  the  circular  hymen  are  the  usual  forms.  The  fimbriated 
hymen  has  a  dentated  or  fringe-like  margin.  The  cribriform  hymen  presents 
a  number  of  small  holes.  In  certain  cases  of  malformation,  the  hymen  is  absent. 
In  other  cases  is  closed  entirely  (imperforate  hymen). 

The  hymen  is  usually  ruptured  at  the  first  sexual  intercourse.  In  some 
cases  ''rupture  of  the  hymen"  amounts  to  nothing  more  than  stretching,  with 
slight  abrasion.  In  other  cases  there  is  distinct  tearing,  with  considerable 
pain  and  some  bleeding.  In  rare  cases  there  may  be  persistent  and  even 
serious  bleeding.  In  some  cases  the  hymen  is  so  rigid  or  tender  as  to  prevent 
coitus.  Long  continued  sexual  intercourse  stretches  the  hymen  until  it  is  not 
at  all  prominent.  Much  medico-legal  importance  has  been  attached  to  the 
condition  of  the  hymen,  and,  ordinarily,  it  is  a  decided  help  in  determining 
whether  or  not  coitus  has  taken  place.  But  it  is  a  well-established  fact  that  an 
intact  hymen  is  not  absolute  proof  of  virginity,  nor  is  an  apparently  rup- 
tured or  stretched  hymen  absolute  proof  of  sexual  intercourse. 

Childbirth  destroys  the  hymen  as  an  intact  ring.  Usually  after  parturition 
there  are  only  irregular  tags  of  tissue  left,  the  result  of  tearing  and  slough- 
ing about  the  vaginal  entrance.  These  irregular  tags  of  tissue  surrounding 
the  vaginal  orifice  are  known  as  "carunculae  myrtif ornies, "  and  result  from 
childbirth  only,  not  from  sexual  intercourse.  Coitus  does  not  usually  de- 
stroy the  hymen,  but  simply  tears  it  slightly  and  stretches  it. 

The  BLOOD  SUPPLY  of  the  external  genitals  (Fig.  452)  comes  principally 
from  the  internal  pudic  artery,  one  of  the  terminal  branches  of  the  anterior 
trunk  of  the  internal  iliac. 

The  LYMPHATICS  EMPTY  into  the  inguinal  glands.  Poirier  calls  attention 
to  the  fact  that  the  lymphatics  from  the  clitoris  extend  into  the  deep  pelvdc 
glands.  Consequently  in  carcinoma  of  the  clitoris  proper  (not  its  prepuce), 
the  glands  within  the  pelvis  are  soon  involved. 

The  NERVE  SUPPLY  (Fig.  452)  comes  principally  from  branches  of  the  pudic 
and  small  sciatic  nerves.  In  certain  painful  affections  of  the  external  geni- 
tals, the  pudic  nerve  is  sometimes  divided  or  resected  to  afford  relief. 

VAGINA 

The  vagina  is  a  musculo-membranous  canal  extending  from  the  vulva  to 
the  neck  of  the  uterus,  around  which  it  is  attached.  It  lies  between  the 
bladder  and  the  rectum   (Figs.  1  and  3). 

Its  size  and  shape  are  very  variable  and  it  is  capable  of  great  distention,  as 
is  seen  when  the  child  passes  through  it  in  labor.  The  length  of  the  vagina 
is  ordinarily  thf'ee  to  four  inches  along  its  anterior  wall,  and  five  to  six 
inches  along  its  posterior  wall.     It  is  constricted  at  its  lower  end,  where  it 


428 


DISEASES    OF    THE    EXTERNAL    GENITALS    AND    VAGINA 


is  partially  closed,  by  the  hymen,  and  it  becomes  dilated  towards  the  uterine 
extremity. 

Normally  the  anterior  and  posterior  vaginal  "walls  lie  in  contact,  and  on 
cross  section  the  cavity  is  represented  by  a  slit  having  somewhat  the  shape  of 
the  letter  H  (Fig.  453).  The  Avide  diameter  of  the  vagina,  some  distance  up 
the  canal,  is  the  transverse  diameter,  but  the  wide  diameter  of  the  vulvar 
cleft  is  the  antero-posterior  diameter.  Furthermore,  the  anterior  end  of  the 
vagina  lies  so  far  up  in  the  narrow  part  of  the  pubic  arch  (in  patients  where 
the  perineum  has  not  been  damaged)  that  there  is  not  much  room  laterally. 
Consequently  in  introducing  the  speculum,  the  preferable  way  is  to  introduce 
one  finger  into  the  vaginal  opening  and  press  the  perineum  well  back  (Fig. 


Fig.  453.  Cross  section  of  the  Pelvic  Structures,  showing  the  relations  of  the  Urethra,  Vagina, 
Rectum  and  Levator  Ani  Muscles.  Notice  how  the  vaginal  walls  fold  so  that  the  shape  of  the  cavity 
approximates  the  letter  H.  Ur.  Urethra.  Va.  A'agina.  R.  Rectum.  L.  Levator  ani  muscle.  (Savage — 
Anatomy    of   Pelvic    Organs.) 


89),  so  that  the  vaginal  opening  is  stretched  antero-posteriorly  and  made  to 
correspond  in  a  measure  Avith  the  vuh'ar  cleft,  and  then  introduce  the  specu- 
lum obliquely  as  shown  in  Figs.  89  and  90.  When  the  speculum  is  well  past 
the  entrance,  so  that  it  may  be  used  to  depress  the  perineum,  it  is  then  turned 
with  its  width  in  the  transverse  diameter  of  the  vaginal  canal  (Fig.  91)  and 
introduced  all  the  Avay.  From  the  author's  experience,  this  is  decidedly 
the  preferable  way  of  introducing  the  speculum,  Avhen  the  perineum  is  in- 
tact and  resisting.  He  considers  erroneous  the  statement  by  some  authorities 
that  the  speculum  should  be  introduced  Avith  the  A^•ide  diameter  transversely, 


POINTS   IN    ANATOMY    OF    VAGINA  429 

"because  the  wide  diameter  of  the  vaginal  canal  is  transverse."  The  specu- 
lum must  first  pass  the  vulvar  cleft  and  vaginal  entrance,  and  we  must  deal 
Avith  the  conditions  found  there  before  accommodating  the  speculum  to  the 
wide  diameter  of  the  canal  proper.  Of  course,  in  a  large  proportion  of  eases 
the  perineum  is  lax  from  damage  and  the  primary  anatomic  relations  are 
destroyed,  and  the  speculum  may  be  introduced  in  any  way  without 
resistance. 

Relations.  Fig.  1  shows  the  angle  which  the  axis  of  the  uterus  normally 
bears  to  the  axis  of  the  vagina.  The  upper  end  of  the  vagina  surrounds  the 
lower  end  of  the  uterus.  That  portion  of  the  cervix  uteri  projecting  into  the 
vagina  is  known  as  the  vaginal  portion  (portio  vaginalis).  The  attachment 
of  the  vagina  extends  higher  on  the  posterior  wall  of  the  cervix  than  on  the 
anterior.  The  vaginal  mucosa  is  continued  on  the  cervix  as  far  as  the 
external  os. 

The  upper  end  of  the  vagina  is  termed  the  "vaginal  vault."  The  term 
"fornix"  is  also  much  used,  the  anterior  fornix  being  that  portion  of  the 
vault  in  front  of  the  cervix,  and  the  posterior  fornix  being  that  portion  lying 
behind  the  cervix,  and  the  right  and  left  lateral  fornix  lying  to  the  right  and  left 
respectively.  With  the  uterus  in  normal  position,  the  posterior  fornix  is 
jnuch  deeper  than  the  anterior,  for  the  vaginal  wall  is  attached  higher  on 
the  posterior  surface  of  the  cervix  than  on  the  anterior. 

The  vagina  is  surrounded  by  important  structures.  The  anterior  wall  is 
in  contact  with  the  urethra  and  the  base  of  the  bladder  (Fig.  1).  The  vagi- 
nal wall  and  bladder  wall  and  the  tissue  lying  between  them,  constitute  the 
vesico-vaginal  septum.  The  posterior  wall  for  the  lower  three-fourths  of  its 
extent  is  attached  to  the  anterior  wall  of  the  rectum,  except  the  very  lowest 
portion,  which  is  separated  from  the  rectal  wall  by  the  perineum.  The  vagi- 
nal and  rectal  walls  and  the  tissue  lying  between  them,  constitute  the  recto- 
vaginal septum.  The  upper  fourth  of  the  posterior  wall  is  separated  from  the 
rectum  by  the  recto-uterine  pouch  of  peritoneum,  known  as  the  "cul-de-sac  of 
Douglas"  (Figs.  3  and  4).  The  sides  of  the  vagina  give  attachment  to  fibers 
from  the  levator  ani  muscles  and  the  recto-vesical  fascia. 

Structure.  The  wall  of  the  vagina  presents  three  layers — an  external  con- 
nective tissue  layer,  a  middle  muscular  layer  and  an  inner  mucous  layer.  The 
CONNECTIVE  TISSUE  layer  serves  to  attach  the  vagina  to  the  adjacent  organs. 
It  contains  the  external  plexus  of  veins,  and  is  composed  of  connective  tissue 
filled  with  lymphatics  and  blood  vessels,  the  veins  being  especially  numer- 
ous. The  attachment  of  the  vagina  anteriorly  is  firm  in  the  lower  third 
where  it  is  attached  to  the  urethra.  It  is  more  loosely  attached  to  the  bladder 
in  the  middle  and  upper  third,  particularly  the  latter,  and  is  easily  separated 
in  operating. 

The  MUSCULAR  LAYER  contains  involuntary  muscle  fibers  arranged  in  bundles 
without  distinct  strata.     Some  of  the  bundles  are  longitudinal,  some  trans- 


430  DISEASES    OF    THE    EXTERNAL    GENITALS    AND    VAGINA 

verse  and  some  oblique.     The  muscular  layer  is  thicker  at  the  lower  than  at 
the  upper  end. 

The  MUCOUS  layer,  or  the  lining  of  the  vagina,  is  apparently  a  modified 
epidermis.  It  presents  on  the  surface  the  usual  layer  of  squamous  epithelium 
several  cells  thick  and,  beneath  this,  connective  tissue  rich  in  cells.  The 
glands  have  all  disappeared  and  the  papillae  are  much  smaller  than  are 
encountered  in  the-  external  genitals.  The  vagina  normally  contains  no  glands. 
The  secretion  found  in  the  vagina  comes  from  the  cervix  and  the  endome- 
trium, principally  the  former.  The  vaginal  walls  are  kept  constantly  moist 
with  the  secretion,  and  consequently  the  epithelium  desquamates  before  it 
advances  so  far  in  the  process  of  cornification  as  is  seen  in  integument.  In 
cases  of  prolapse,  where  the  vagina  is  turned  outside  the  vulva  and  is  sub- 
jected to  friction  of  the  clothing  and  is  kept  dry  by  contact  with  them, 
it  becomes  more  like  ordinary  epidermis  and  shows  well-marked  keratin 
changes.  The  mucosa  (epithelium  and  connective  tissue  immediately  under 
it)  is  attached  to  the  muscular  coat  by  a  submucous  layer  of  loose  connective 
tissue  which  is  very  rich  in  interlacing  veins,  about  some  of  Avhich  are  bundles 
of  muscular  fibres,  forming  a  kind  of  cavernous  tissue. 

The  vaginal  mucosa  is  thrown  into  numerous  large  folds  called  "rugae." 
Extending  longitudinally  along  both  the  anterior  and  the  posterior  wall  of 
the  vagina  is  a  prominent  ridge,  best  marked  in  the  virgin.  These  ridges 
are  known  as  the  "columns"  of  the  vagina,  and  from  them  the  rugae  extend 
laterally.  The  columns  and  rugae  become  more  or  less  obliterated  by  child- 
birth, so  that  in  many  multiparae  the  vaginal  walls  are  almost  smooth. 

Vessels  and  Nerves.  The  blood  supply  of  the  vagina  comes  from  the 
anterior  trunk  of  the  internal  iliac,  through  the  vaginal,  uterine,  middle 
hemorrhoidal  and  internal  pudic  arteries.  These  anastamose  freely  in  the 
vaginal  wall.  The  veins  of  the  vagina  are  arranged  principally  in  two  plexus 
that  form  complete  vascular  sheaths  around  the  canal.  One  plexus  is  external 
to  the  muscular  layer,  while  the  other  lies  just  beneath  the  mucosa.  These 
veins  form  an  intricate  network  and  communicate  freely  with  the  plexus  of 
the  other  organs  and  with  the  plexus  of  the  broad  ligament. 

The  lymphatics  from  the  lower  third  of  the  vagina,  it  is  generally  held,  join 
those  from  the  external  genitals  and  empty  into  the  inguinal  glands.  But 
Poirier,  who  has  made  a  special  study  of  the  subject,  claims  that  all  the 
'  lymphatics  of  the  vagina  empty  into  the  pelvic  glands  and  that  when  an 
injection  of  the  vaginal  lymphatics  is  made,  even  just  within  the  hymen,  no 
injection  material  passes  to  the  inguinal  glands  except  through  some  anas- 
tomosing channels.  The  lymphatics  from  the  middle  third  of  the  vagina 
empty  into  the  hypogastric  glands.  Those  from  tlie  upper  third  join  with 
the  lymphatics  of  the  cervix  uteri  and  pass  to  the  iliac  glands. 

The  NERVE  SUPPLY  of  the  vagina  comes  from  pelvic  plexus  of  each  side. 


GONORRHEA  431 

CLASSIFICATION  OF  DISEASES 

Of  The  External  Genitals  and  Vagina  - 

Gonorrhea. 

Other  Inflammatory  Diseases  of   the  Vulva — Simple  Vulvitis,   Follicular 

Vulvitis,  Erysipelas,   Cellulitis,   Gangrene,  Diphtheria,  Eczema  Intertrigo, 

Herpes,  Prurigo,  Parasitic  Diseases. 
Other  Inflammatory  Diseases  of  the   Vagina — Simple  Vaginitis,  Parasitic 

Vaginitis,    Diphtheritic    Vaginitis,    Emphysematous    Vaginitis,    Adhesive 

Vaginitis. 
Ulcers  of  Vulva  and  Vagina— Simple  Ulcer,'  Chancroid,   Syphilis,   Tubercu- 
losis, Malignant  Disease,  Ulcus  Rodens  Vulvae. 
Urethral  Affections — Urethritis,  Periurethral  Abscess,  Prolapse  of  Urethral 

Mucosa,  Urethral  Caruncle. 
VuLVO-VAGiNAL  Gland  AFFECTIONS — Inflammation,  Abscess,   Sinus,   Cyst. 
Non-malignant    Growths    and    Swellings — Condylomata,  Cysts,  Fibromata, 

Lipomata,  Stasis  Hypertrophy^,  Elephantiasis,  Pudendal  Hernia,  Pudendal 

Hydrocele,  Hematoma,  Varicose  Veins. 
Injuries  of  Vulva  and  Vagina. 
Miscellaneous  Affections — Kraurosis  Vulvae,  Pruritus  Vulvae,  Hyperesthesia 

of  Vaginal  Entrance,  Adhesions  of  Prepuce  and  Labia. 

(The  more  pronounced  Malformations  are  considered  in  Chapter  xiii.) 

GONORRHEA 

Gonorrhea  is  inflammation  of  the  genital  organs  produced  by  the  gono- 
coccus.  The  term,  when  not  qualified,  is  understood  to  mean  gonorrheal  in- 
flammation of  the  vulva,  vagina  and  urethra,  i.e.,  gonorrheal  vulvitus,  vaginitis 
and  urethritis.  If  the  process  extends  into  the  uterus  or  Fallopian  tubes  or 
bladder,  it  causes  complications  known  respectively  as  gonorrheal  endome- 
tritis, gonorrheal  salpingitis  and  gonorrheal  cystitis.  Gonorrhea  is  some- 
times referred  to  as  "specific"  vaginitis  or  vulvitis  or  urethritis. 

ETIOLOGY 

Gonorrhea  is  caused  by  contact  of  the  affected  organs  with  a  gonorrheal 
discharge,  usually  in  sexual  intercourse.  The  infecting  germ  (the  gonococ- 
cus)  is  a  diplococcus,  easily  stained,  and  is  found  in  large  numbers  in  the 
pus  cells  of  all  acute  gonorrheal  discharges  (Fig.  454).  In  chronic  gonorrheal 
discharges  it  is  not  found  so  abundantly,  in  fact,  in  some  cases  it  is  so  scarce 
as  to  be  very  hard  to  find,  and  may  even  disappear  entirely  for  a  time. 

All  discharges  containing  the  gonococcus  are  capable  of  causing  gonorrhea. 


4-32  DISEASES   OF    THE   EXTERNAL    GENITALS   AND   VAGINA 

The  slight  urethral  discharge  from  a  chronic  deep  urethritis  or  from  a  stric- 
ture, persisting  months  or  years  after  an  attack  of  gonorrhea  in  the  male,  is 
very  liable  to  cause  gonorrhea  when  brought  in  contact  with  virgin  soil. 

A  sad  exemplification  of  this  fact  is  seen  in  the  many  instances  in  which  a 
bride  is  infected  by  her  husband,  w^ho  had  gonorrhea  years  before  but  sup- 
posed himself  well.  The  consequence  of  such  infection  is  that,  instead  of  a 
healthy,  happy  w^oman  with  sons  and  daughters,  the  wife  becomes  a  confirmed 
invalid  in  a  childless  home.  This  danger  is  not  sufficiently  appreciated  by  men 
generally — in  fact,  the  man  usually  does  not  know  the  danger  until  too  late. 
The  responsibility  of  physicians  in  this,  matter  is  great,  for  the  physician  must 
decide  when  a  man  who  has  had  gonorrhea  may  safely  marry. 

The  report  of  the  special  committee  appointed  by  the  American  Medical 
Association  to  consider  this  question,  is  worthy  of  study  (Journal  A.  M.  A., 
March  30,  1901).  The  committee  was  appointed  to  determine  whether  a  man 
who  has  had  gonorrhea  may  ever  safely  marry,  and,  if  so,  when!  Careful 
inquiries  were  made  and  replies  were  received  from  the  leading  teachers  of 
genito-urinary  surgery  in  this  country  and  in  Europe. 

Among  the  questions  asked  were  the  following,  concerning  of  course  gon- 
orrhea in  the  male : 

1.  Is  gonorrhea  curable — so  curable  that  the  physician  can  confidently  say 
to  his  patient,  "You  may  marry  now;  you  run  no  risk  of  infecting  your 
wife?" 

2.  Upon  what  tests  do  you  rely  in  order  to  determine  positively  w-hether 
the  patient  is  wholly  free  from  the  gonococcus  and  is  not  infectious? 

3.  What  period  of  time  should  elapse  after  the  disappearance  of  the  last 
evidence  of  the  gonococcus  before  the  patient  should  be  permitted  to  marry? 

The  following  fairly  represents  the  concensus  of  opinion  of  the  authorities 
quoted  in  that  report : 

1.  Curability.     Gonorrhea  is  curable  with  the  following  exceptions: 

a.  Gonorrhea  is  not  curable  in  the  sense  that  the  physician  can  guarantee 
that  no  infection  will  result  therefrom,  but  so  that  in  good  conscience  he  can 
give  an  assurance  that,  in  all  human  probability,  no  infection  will  result. 

b.  There  are  a  few  cases  (estimated  by  one  authority  as  about  3%)  w^hich, 
on  account  of  an  especially  deep-seated  lesion  or  serious  complications,  are 
incurable.     These  patients  can  never  safely  marry. 

2.  Determination  of  Cure.  All  agree  that  the  examination  must  be 
thorough  and  repeated,  and  that  only  on  the  basis  of  repeated  negative  ex- 
aminations, conducted  over  a  considerable  period  of  time,  should  the  con- 
clusion be  reached  that  the  patient  is  no  longer  infectious. 

The  following  points  are  insisted  on: 

a.  Absence  of  the  gonococcus. 

b.  Absence  of  pus  germs. 

c.  Absence  of  pus  cells. 


PATHOLOGY  OF  GONORRHEA  433 

It  is  pointed  out  that  the  ordinary  pus  germs  may  cause  trouble,  and  that 
cases  have  occurred  in  which  the  husband  carried  to  the  wife  a  pyogenic 
infection  causing  serious  pelvic  disease,  though  the  gonococcus  had  entirely 
disappeared  and  did  not  reappear  in  either  husband  or  wife. 

3.  Time  Limit.  The  period  of  time  which  should  elapse  after  the  disappear- 
ance of  the  last  evidence  of  the  gonococcus  before  the  patient  should  be  per- 
initted  to  marry,  is  given  by  several  authorities  as  one  year.  Others  state 
three  months  to  a  year,  depending  on  the  circumstances  of  the  case. 

Though  the  usual  cause  of  gonorrhea  is  sexual  contact  with  an  infected 
person,  it  may  exceptionally  be  caused  by  other  means,  as  by  contact  with 
an  infected  towel  or  douche  nozzle  or  chamber  utensil  or  closet-seat, 

PATHOLOGY 

There  is  acute  inflammation  of  the  vulva  and  usually  of  the  vagina  and  of 
the  urethral  mucous  membrane  near  the  meatus. 

There  are  present  the  cardinal  signs  of  inflammation- — heat,  pain,  redness 
and  the  swelling.  There  is  at  first  abnormal  dryness  of  the  parts,  then  a 
slight  secretion,  which  rapidly  increases  in  a  day  or  two,  and  when  the 
inflammation  is  well  established  it  becomes  a  free  yellow  discharge,  causing 
much  irritation  of  the  adjacent  surfaces.  There  is  the  ordinary  serous  and 
cellular  infiltration  into  the  involved  areas.  The  most  superficial  layers  of 
epithelium  are  thrown  off  and  the  gonococci  penetrate  the  underlying  tissues 
to  a  greater  or  less  extent,  depending  on  the  severity  and  duration  of  the 
inflammation.  There  may  be,  later,  a  mixed  infection,  one  or  more  of  the 
ordinary  pus  germs  being  found  with  the  gonococcus. 

The  process  may  affect  only  the  vulva  or  the  upper  part  of  the  vagina. 
Some  authorities  state  that  this  is  the  rule,  but  in  the  author's  experience 
such  limitation  is  exceptional  in  adults  with  primary  infection,  the  first 
examination  usually  showing  involvement  of  practically  all  of  the  vaginal 
wall. 

The  gonorrheal  inflammation  is  very  liable  to  extend  into  one  or  both  of 
the  vulvo-vaginal  glands  or  into  the  cervix  uteri,  and  to  remain  active  there 
after  all  other  symptoms  have  disappeared. 

In  the  gonorrhea  of  children  the  process  is  usually  limited  to  the  vulva 
and  urethra,  for  the  reason  that  penetration  of  the  vagina  by  the  infection 
carrier  rarely  takes  place. 

In  reinfection  in  adults,  the  process  is  comparatively^  mild  and  is  usually 
limited  to  certain  areas,  for  example  the  Aailva  or  urethra  or  upper  part  of 
the  vagina. 

The  gonococcus  seems  to  thrive  best  in  the  urethral  mucous  membrane,  and 
it  may  penetrate  into  Skene's  glands  and  remain  there  indeflnitely. 


434  DISEASES    OF    THE    EXTERKAL    GENITALS   AND   VAGINA 

SYMPTOMS 

Within  a  few  days  after  suspicious  coitus  the  patient  complains  of  slight 
irritation  about  the  genitals.  The  parts  feel  dry  and  uncomfortable,  and 
there  may  be  a  slight  burning  sensation.  The  feeling  of  discomfort  increases 
and  a  discharge  appears.  About  the  same  time  or  a  little  later,  there  is  noticed 
a  smarting  or  burning  on  urination  and  increased  frequency  of  urination. 
Within  two  or  three  days  of  the  beginning  of  the  trouble  the  discharge  is 
profuse  and  the  signs  of  irritation  (burning  and  itching  and  frequent  pain- 
ful urination)   are  marked. 

On  inspection,  the  structures  immediately  surrounding  the  vaginal  orifice 
are  found  reddened  and  painful  on  pressure.  There  is  a  yellow  discharge 
from  the  vagina  and  frequently  some  discharge  from  the  urethra.  Acute 
gonorrheal  discharge  leaves  a  yellow  stain  where  it  dries  on  the  clothing. 

On  digital  examination,  the  vaginal  walls  are  found  rough  and  hot  and 
,  tender.  Pressure  on  the  anterior  vaginal  wall  directed  from  the  upper  end 
of  the  urethra  to  tlie  meatus,  v/ill  bring  to  view  one  or  more  drops  of  urethral 
pus  (Figs.  42,  43).  If  the  ease  has  passed  beyond  the  acute  stage,  the  pain 
and  discomfort  are  not  so  marked,  but  the  discharge,  more  or  less  profuse,  is 
still  present. 

DIAGNOSIS 

Gonorrhea  must  be  distinguished  from  vulvitis  and  vaginitis  due  to  various 
other  causes. 

The  distinguishing  characteristics  of  gonorrhea  are  as  follows: 

1.  Rapidity  of  Development  and  Severity  of  Symptoms.  The  inflammation 
with  its  accompanying  symptoms  usually  reaches  its  height  within  the  first 
week  and  then  begins  to  subside.  As  a  rule  with  but  few  exceptions,  other 
inflammations  of  the  vagina  are  not  so  severe  nor  the  discharge  so  profuse. 
Occasionally  there  occur  instances  of  very  mild  gonorrheal  infection.  This 
mild  reaction  to  the  gonococeus  is  found  almost  exclusively  in  tissues  that 
have  suffered  previous  gonorrheal  infection  or  that  have  become  somewhat 
hardened  by  frequent  child-bearing. 

2.  Involvement  of  the  Urethra  and  Vulvo-Vaginal  Glands  or  Ducts.  These 
extensions  of  the  inflammatory  process  are  rare  in  ordinary  pus  infection. 
In  fact  the  involvement  of  the  meatus  and  of  the  openings  of  the  ducts  of 
the  vulvo-vaginal  glands  is  so  constant  in  gonorrhea  and  so  infrequent  in 
other  forms  of  inflammation,  that  some  authors  hold  that  it  can  be  determined 
whether  or  not  a  patient  has  ever  had  gonorrhea  by  determining  the  pres- 
ence or  absence  of  evidence  of  previous  inflammation  of  the  structures  just 
mentioned.  Such  evidences  are  a  reddish  margin  around  the  meatus,  with 
rolling  outward  and  chronic  congestion  of  the  urethral  mucous  membrane, 
and  a  bright  red  spot  marking  the  orifice  of  the  vulvo-vaginal  gland  of  each 


DIAGNOSIS   OF   GONORRHEA  435 

side  (so-called  "gonorrheal  maculae"),  and  sometimes  pressure  on  tlie  gland 
will  cause  pus  to  appear  at  the  opening  of  the  duct  (Fig.  46).  Though  such 
inflammation  is  usually  caused  by  gonorrhea,  it  occasionally  occurs  from  other 
causes,  and  consequently  is  not  an  absolute  indication  of  previous  gonorrhea. 

3.  No  Other  Apparent  Cause  for  the  Inflammation.  Vaginitis  other  than 
gonorrheal  presents  some  cause  for  its  existence,  for  example,  pus  infection 
following  labor  or  abortion,  the  use  of  an  infected  douche  nozzle  or  the 
development  of  that  local  nutritive  change  which  causes  senile  vaginitis. 

4.  Development  Within  a  Few  Days  After  Sexual  Intercourse.  Consider- 
able pain  from  slight  traumatism  and  some  bladder  disturbance  may  follow  coitus, 
particularly  in  the  newly  married,  but  such  eases  do  not  present  the  profuse 
yellow  discharge  of  gonorrhea.  In  the  case  of  a  married  woman,  be  careful 
not  to  question  her  in  such  a  way  as  to  associate  the  trouble  with  coitus,  as 
it  may  arouse  her  suspicion  and  cause  trouble  in  the  family. 

5.  Presence  of  the  Gonococcus.  The  presence  of  the  gonococcus  is  de- 
termined by  microscopic  examination  of  the  pus  from  the  infected  areas. 
With  the  tip  of  the  applicator  take  a  small  amount  of  the  urethral  discharge 
and  spread  it  in  a  thin  film  on  two  glass  slides,  or  on  cover-glasses  if  pre- 
ferred. If  using  cover-glasses,  spread  four  or  five  with  the  urethral  pus,  for 
some  may  get  broken.  If  desired,  specimens  of  pus  may  be  taken  from  other 
localities  also,  for  example,  from  the  ducts  of  the  vulvo-vaginal  glands  or 
from  the  upper  or  lower  parts  of  the  vagina  or  from  the  cervix,  the  specimens 
from  the  different  localities  being  designated  as  described  on  page  35. 

Staining  the  Gonococcus 

One  of  the  spread  preparations,  on  a  cover-glass  or  a  glass  slide,  is  stained 
by  a  methylene-blue  solution.  If  the  microscopic  findings,  taken  in  connec- 
tion with  the  history  of  the  case  and  the  physical  signs,  make  the  diagnosis 
clear,  no  -further  staining  is  necessary.  If  it  is  doubtful,  then  another  pre- 
pared cover-glass  or  slide  is  subjected  to  Gram's  deeolorization  method. 

The  details  of  staining  are  practically  the  same  whether  the  preparation 
be  on  the  glass  slide  or  on  a  cover-glass.  The  cover-glass  is  held  in  a  forceps, 
while  the  slide  is  held  in  the  fingers. 

We  will  suppose  the  preparations  are  on  cover-glasses  and  were  made  some 
minutes  ago  and  laid  aside,  while  the  other  steps  in  the  diagnosis  and  treat- 
ment were  carried  out  and  the  patient  dismissed. 

The  cover-glasses  are  now  dry  and  ready  to  be  stained. 

1.  Staining  with  Methylene-blue  Solution.    The  steps  in  this  process  are  as 

follows  : 

a.  With  the  cover-glass  forceps  pick  up  one  of  the  prepared  cover-glasses, 
charged  side  up,  and  pass  it,  rather  sloAvly,  three  or  four  times  through  the 
fiame  of  the  Bunsen  burner  or  alcohol  lamp.  This  "fixes"  the  specimen  to 
the  glass,  so  it  is  not  washed  off  in  the  subsequent  manipulations. 


436  DISEASES   OP   THE  EXTERNAL  GENITALS   AND  VAGINA 

b.  Flood  the  prepared  surface  of  the  cover-glass,  held  in  the  forceps,  with 
a  few  drops  of  Loeffler's  alkaline  methylene-blue  solution  or  1%  aqueous 
(fresh)  of  methylene-blue.  Hold  the  cover-glass  high  above  the  flame,  so  that 
it  steams  some  but  does  not  boil,  for  about  half  a  minute.  This  stains  the 
specimeai. 

c.  Then  wash  off  the  excess  of  stain  with  clear  water. 

d.  Then  lay  the  cover-glass,  charged  surface  down,  on  a  clean  glass  slide 
and  remove  the  excess  of  water  and  dry  the  upper  surface  of  the  cover-glass 
with   blotting   paper. 

e.  Put  on  a  drop  of  cedar  oil  and  examine  with  the  oil-immersion  lens. 
The  microscope  for  this  work  should  be  provided  with  a  1-12  inch  oil-immer- 
sion lens  and  an  Abbe  condenser.  The  cover-glasses  should  be  very  thin  (No. 
1).  The  No.  2  cover-glasses  do  not  break  so  easily,  but  every  once  in  a  while 
there  is  one  that  is  too  thick  for  the  use  of  the  oil-immersion  lens.  The  cover- 
glasses  may  be  kept  in  alcohol  in  a  flat  wide-mouthed  bottle,  from  which  they 
are  removed  and  dried  (cleaned)  as  needed. 

In  the  methylene-blue  specimen,  the  nucleus  of  each  pus  cell  is  stained  a 
light  blue.  These  nuclei  are  very  irregular  in  shape  and  some  of  them  are 
broken  into  two  or  more  parts.  They  form  the  prominent  light  blue  masses 
which  largely  occupy  the  field.  The  protoplasm,  or  body,  of  each  cell  is 
stained  only  very  faintly,  so  faintly  that  it  is  ill-defined  and  hardly  noticeable. 
All  bacteria  taking  the  stain,  including  the  gonococci,  are  stained  a  very  dark 
blue  (almost  black)  and  contrast  well  with  the  light  blue  nuclear  masses. 

In  vaginal  specimens,  the  field  is  so  filled  with  bacteria  of  various  shapes 
and  sizes,  that  the  gonococci  are  more  or  less  obscured.  In  urethral  speci- 
mens, however,  there  are  as  a  rule  but  few  other  bacteria  and  consequently 
the  gonococci  are  more  easily  found. 

In  acute  gonorrhea  the  gonococci  are  seen  lying  in  colonies  in  the  pus 
cells  (Fig.  454)  with  a  few  scattered  between  the  cells.  They  occur  as  diplo- 
cocci,  the  two  together  having  about  the  shape  of  two  coffee  grains  with  their 
flat  surfaces  turned  toward  each  other  and  slightly  separated  (Fig.  455). 
They  are  spoken  of  as  '* biscuit-shaped"  or  "roll-shaped." 

The  occurrence  of  the  gonococci  in  small  detached  groups  (Fig.  454),  is  a 
striking  feature  in  a  good  specimen.  The  little  colonies  occur  inside  the  pus 
cells,  the  pus  cell  being  recognized  by  the  well-marked  blue  nucleus  of  irregu- 
lar shape.  The  protoplasm  is  hardly  visible,  but  it  is  known  that  the  gon- 
ococci must  be  within  the  cell  because  they  are  grouped  so  closely  about  the 
nucleus.  In  some  cases  the  cell  has  broken  down  and  the  colony  has  out- 
grown its  dimensions.  But  the  colony  is  still  close  to  the  disintegrating  nu- 
cleus, and  the  outlines  of  the  colony  have  the  general  circular  shape  of  the 
cell  which  recently  housed  it.  At  some  other  point  a  cell  has  advanced  still 
further  in  the  process  of  disintegration  and  has  largely  disappeared  and  the 
colony  of  gonococci  has  broken  up,  the  individual  gonococci  being  scattered 


DIAGNOSIS   OF   GONORRHEA  437 

through  the  space  between  the  other  cells.  Only  comparatively  few  of  the 
pus  cells  show  a  gonococcus  colony.  In  some  cases  several  microscopic  fields, 
filled  with  pus  cells,  may  be  looked  over  without  seeing  a  gonococcus,  and  then 
a  pus  cell  with  a  fine  colony  is  encountered. 

The  disting-uishing  characteristics  of  the  gonococci  are : 

a.  Roll-shaped  diplococci,  occurring  in  detached  groups  or  colonies. 

b.  Presence  within  the  pus  cells. 

c.  Decolorization  by  Gram's  method  of  staining. 

In  acute  cases  it  is  rarely  necessary  to  stain  by  Gram's  method.     If  the 


€»0 


Fig.  454.     Specimen    of   pus    from    a    case    of    Gonor-  Fig.  45 S.     Indicating    the    Shape    of 

rhea,    stained    with    Methylene-blue.      This    field    contains  the  diplococcus  of  gonorrhea   (Gonococ- 

two  gonococcus-colonies,  each  within  a  pus  cell.     Only  the  cus).    (Byford — Manual  of  Gynecology.) 

nuclei  of  the  pus  cells  are  seen.  The  lower  colony  has 
the  circular  outline  of  the  cell  containing  it.  (Kolle  and 
Wassermann — Handbuch  der  Pathogenen  Mikroorgan- 
isnien.) 

patient  gives  the  clinical  history  and  evidences  of  acute  or  subacute  gonor- 
rhea, and  the  microscopic  examination  of  the  discharge  shows  a  diplococcus 
within  the  pus  cells,  presenting  the  form  of  the  gonococcus  and  occurring 
in  large  numbers  and  arranged  in  groups  and  without  other  bacteria  to  ac- 
count for  the  discharge,  that  patient  has  gonorrhea  beyond  a  reasonable 
doubt. 

If  the  patient  presents  the  clinical  evidences  of  acute  gonorrhea  and 
microscopic  examination  of  the  discharge  shows  the  absence  of  a  diplococcus, 
such  as  above  described,  the  strong  probability  is  that  the  trouble  is  not 
gonorrheal,  though  it  is  well  to  make  more  than  one  examination  (differ- 
ent  days)  before  deciding  adversely  to  the  ordinary  clinical  evidences. 


438  DISEASES    OF    THE   EXTERNAL   GENITALS   AND   VAGINA 

111  the  acute  inflammations  that  are  not  gonorrheal,  there  is  usually  found 
some  other  germ,  of  sufficient  virulence  and  in  sufficient  numbers,  to  ac- 
count for  the  discharge.  If  there  is  any  question  as  to  the  identity  of  the 
supposed  gonococci,  preparations  should  be  subjected  to   Gram's  stain. 

2.  Decolorization  by  Gram's  Method.  The  feature  of  Gram's  staining 
method  is  that  certain  bacteria  are  stained  by  it  (Gram-positive  bacteria) 
while  others  are  decolorized  and  hence  do  not  appear  in  the  specimen  (Gram- 
negative  bacteria).  The  gonococcus  is  "Gram-negative,"  hence  it  is  not 
seen  in  a  specimen  so  prepared.  The  value  of  this  lies  in  the  fact  that  certain 
other  bacteria  resembling  the  gonococcus  closely  as  to  form,  are  Gram-posi- 
tive and  hence  appear  deeply-stained  in  a  Gram  preparation. 

Consequently  in  an  acute  case,  if,  after  examining  a  specimen  of  pus 
stained  with  the  methylene-blue  solution,  and  finding  bacteria  of  the  form  and 
distribution  of  the  gonococcus  (Fig.  479),  another  specimen  of  the  same  pus 
is  stained  by  Gram's  method  and  these  bacteria  do  not  appear  (Fig.  481), 
the  bacteria  in  question  are  certainly  gonococci. 

The  regular  Gram  method  is  quite  long  and  troublesome.  Dr.  E.  F. 
Tiedemann,  Professor  of  Pathology  in  Washington  University,  has  devised  a 
convenient  modification  of  it: 

''1.  Make  a  thin  smear  on  a  cover-glass. 

''2.  Dry  in  the  air. 

"3.  Without  fixation,  flood  the  cover-glass,  held  by  forceps,  \vith  a  2 
per  cent  solution  of  crystal  violet  (Hoechst,  pure)  in  methyl  alcohol.  Allow 
the  stain  to  act  for  15  seconds ;  wash  off  the  stain  slowly  with  distilled  water, 
by  letting  it  fall  on  drop  by  drop  from  a  pipette ;  this  takes  about  10  seconds ; 
then  wash  both  surfaces  of  the  cover-glass  briskly  with  distilled  water. 

"4.  Flood  the  cover-glass  with  the  following  solution: 

Iodine,  1  gram. 

Potassium  iodide,  2  grams. 

Distilled  water,  100  c.c. 
Allow  this  to  act  for  15  seconds. 

"5.  Pour  off  the  iodine  solution  and  pour  on  95  per  cent  alcohol,  at  first 
quickly,  then  slowly  until  no  more  color  is  given  off.  This  takes  about  10 
seconds. 

*'6.  Wash  thoroughly  with  distilled  water  and  mount  in  water,  or— 
after  drying — in  balsam. 

"The  Gram-positive  bacteria  appear  bluish-black. 

"The  advantages  are:  Absence  of  fixation,  the  use  of  a  simple  methyl- 
alcohol  solution  of  the  dye  which  keeps  indefinitely  instead  of  the  usual 
aniline-water  gentian-violet  solution,  which  is  troublesome  to  prepare  and 
keeps  only  for  a  few  weeks,  the  use  of  ordinary  95  per  cent  alcohol  in  place 
of  the  absolute  alcohol  usually  advised,  and  finally  the  shortening  of  the 


DIAGNOSIS    OF    GONORRHEA  439 

various  steps;  the  entire  process  is  completed  within  one  minute  after  the 
violet  stain  is  applied. 

''Grentian  violet  or  methyl  violet  may  be  used  in  the  same  manner  and 
strength  in  the  place  of  crystal  violet,  but  the  last  named  gives  the  best  re- 
sults. 

"Methyl  alcohol  can  not  be  substituted  for  ethyl  alcohol  for  decolorizing, 
because  it  dissolves  out  all  the  stain  from  the  Gram-positive  bacteria. 

"It  is  possible  to  combine  the  violet  stain  with  iodine  in  one  solution 
and  to  stain  with  this  mixture .  and  then  apply  alcohol,  which  will  remove 
the  color  only  from  the  Gram-negative  bacteria.  But  the  results  are  not  so 
good,  and  the  method  above  given  is  already  so  simple  that  I  do  not  advise 
the  combination  of  the  violet  stain  with  iodine  in  one  mixture. 

"Experience  has  shown  that  the  alcohol  removes  the  stain  completely 
from  the  Gram-negative  bacteria  in  a  few  seconds,  but  will  take  it  from  the 
Gram-positive  bacteria  only  after  the  lapse  of  some  minutes." 

Significajice  of  the  Microscopic  Findings 

In  a  few  cases,  diplococci  showing  the  staining  qualities  of  gonococci 
liave  been  found  in  patients  where  apparently  there  has  never  been  gonor- 
rhea. Both  such  cases  are  exceptional  and  only  serve  to  show  that  the 
positive  diagnosis  of  gonorrhea  must  rest  on  the  clinical  symptoms  and 
microscopic  findings  together,  and  not  on  the  microscopic  findings  alone. 

As  already  stated,  in  acute  and  subacute  cases  there  is  rarely  any  dif- 
ficulty in  determining  certainly  whether  the  trouble  is  or  is  not  gonor- 
rheal. 

In  chronic  cases,  on  the  other  hand,  there  is  often  great  difficulty.  If  a 
few  apparent  gonococci  (shape,  groupings,  situated  in  pus  cells,  decolorized 
by  Gram's  method)  are  found,  the  diagnosis  is  not  positive  (may  be  "pseudo- 
gonococci"),  though  the  strong  probability  is  that  the  lesion  is  gonorrheal, 
if  the  history  and  ordinary  examination  findings  point  that  way.  The  em- 
ployment of  culture  methods  by  a  skilled  pathologist  may  aid  some  in  decid- 
ing the  question  in  a  doubtful  case. 

If  no  apparent  gonococci  are  found  in  a  chronic  discharge,  that  is  not 
proof  that  the  lesion  is  not  gonorrheal.  In  many  cases  of  chronic  discharge 
from  lesions  that  are  undoubtedly  gonorrheal,  no  gonococci  are  found,  be- 
cause they  have  temporarily  disappeared  from  the  secretion.  But  they  lie 
hidden  in  the  tissues  from  which  the  discharge  comes  and  are  still  ca- 
pable of  causing  infection,  and  they  are  likely  to  be  excited  to  activity  by 
anything  that  causes  pelvic  congestion,  as,  for  example,  sexual  intercourse 
or  an  attack  of  pelvic  inflammation. 

Thus  it  is  seen  that  the. presence  or  absence  of  apparent  gonococci  falls 
short  of  decisive  import  in  a  considerable  proportion  of  cases  of  chronic  dis- 
charge. ,      , 


440  DISEASES   OF    THE   EXTERNAL   GENITALS   AND   VAGINA 

Diagnosis  in  Doubtful  Chronic  Cases 

In  the  doubtful  chronic  cases,  just  referred  to,  an  approximately  correct 
diagnosis  may  be  made  by  giving  attention  to  the  following  points: 

1.  Careful  consideration  of  the  clinical  history  as  pointing  to  previous 
gonorrhea  or  excluding  the  same.  In  this  connection,  it  must  be  borne  in 
mind  that  in  the  adult  married  woman,  particularly  after  the  vagina  has  been 
toughened  by  child-bearing,  gonorrhea  may  produce  but  slight  inflamma- 
tion of  the  vagina,  and  hence  might  be  missed  entirely  in  the  history.  A 
point  against  gonorrhea  is  that  the  inflammatory  trouble  was  apparently 
caused  by  infection  following  labor  or  abortion  or  by  instrumentation  or  by 
some  other  sufficient  cause  aside  from  coitus.  Eemember,  howeve.r,  that 
an  old  gonorrhea  may  be  stirred  up  by  labor  or  abortion.  From  a  chronically 
inflamed  vulvo-vaginal  gland  or  cervix  uteri,  the  infection  may  spread  up- 
ward into  the  body  of  the  uterus  and  there  set  up  a  puerperal  gonorrheal  en- 
dometritis. This  may  be  the  first  decided  intimation  the  patient  has  of  her 
gonorrheal  infection.  The  discharge  from  such  a  fresh  focus  usually  shows 
undoubted  gonococci  in  abundance,  if  the  patient  happens  to  be  seen  at  that 
time. 

2.  Evidence  of  inflammation  of  the  urethra  or  of  the  duct  of  one  or 
both  vulvo-vaginal  glands. 

3.  The  presence  in  the  discharge  of  a  germ  presenting  the  characteristics 
of  the  gonococcus.  In  a  patient  who  has  once  had  gonorrhea,  the  presence 
in  the  discharge  of  such  a  germ  is  strong  presumptive  evidence  that  the 
gonorrheal  process  is  still  active. 

4.  Effect  of  treatment.  A  chronic  inflammatory  trouble  due  to  the  gono- 
coccus is  usually  more  resistant  to  treatment  than  when  due  to  other  causes. 

5.  Tubal  complications.  Chronic  salpingitis  is  much  more  frequent  and 
persistent  in  gonorrheal  than  in  other  forms  of  endometritis.  Also,  it  is  more 
frequently  bilateral. 

6.  Sterility.  Persistent  sterility  is  one  of  the  marked  characteristics  of 
gonorrheal  inflammation,  much  more  so  than  of  the  ordinary  pyogenic  infec- 
tion. 

7.  History  of  gonorrhea  in  the  husband.  This  fact,  if  established,  would 
of  course  help  much  in  the  diagnosis  in  a  doubtful  case.  In  such  a  case  the 
husband  should  be  seen  and  questioned.  As  a  rule  no  question  on  this 
point  should  be  asked  the  wife,  as  it  might  arouse  suspicion  in  her  mind, 
and  cause  domestic  trouble  that  would  bring  more  unhappiness  than  the 
pelvic  disease. 

8.  Complement-flxation  test,  if  distinctly  positive. 

TREATMENT 

The  treatment  of  acute  gonorrhea  in  women,  like  the  treatment  of  the 
same  disease  in  men,  has  been  the  subject  of  much  experimentation  and  of 


.  TEEATMENT   OF    GONOREHEA  441 

many  different  conclusions.  The  treatment  employed  by  different  author- 
ities varies  all  the  way  from  the  most  active  and  radical  interference  to 
practically  no  treatment  beyond  some  external  cleansing. 

Before  stating  in  detail  the  methods,  it  will  be  desirable  to  describe 
clearly  principal  purposes  of  the  treatment.     They  are  as  follows : 

a.  To  Prevent  Extension  Upward  of  the  disease  to  the  endometrium  and 
Fallopian  tubes.  The  extension  to  the  Fallopian  tubes  is  the  most  serious 
result  of  gonorrheal  infection  and  condemns  a  large  proportion  of  the  vic- 
tims to  chronic  invalidism  or  to  a  serious  operation.  In  either  case,  there 
will  probably  be  sterility. 

b.  To  Completely  Eradicate  the  Infection  from  the  lower  genital  tract  so 
that  no  infective  discharge  will  remain.  As  long  as  one  spot  of  gonorrheal 
inflammation  remains  in  the  vagina  or  in  the  vulvo-vaginal  glands  or  in 
the  urethra  or  in  the  uterus,  the  discharge  is  infective  and  is  a  source  of  dan- 
ger to  the  patient  and  to  those  around  her.  At  any  time,  there  may  be  an 
extension  upward  to  the  tubes  or  there  may  be  infection  of  the  eyes  of  the 
patient  or  of  some  one  else  in  the  household.  It  is  probable  that  a  consider- 
able number  of  the  cases  of  gonorrheal  vulvitis  in  children  come  from  acci- 
dental infection  from  a  contaminated  towel  or  closet-seat,  in  the  home  or 
elsewhere. 

c.  To  Relieve  the  Discomfort  attendant  on  the  inflammation  and  to  pre- 
vent contamination  of  the  patient's  clothing  and  surrounding  objects  with 
the  discharge. 

It  must  be  recognized  at  the  start  that  the  principal  influences  pre- 
venting extension  upward  of  gonorrhea,  are  the  resistance  of  the  tissues  and 
the  barriers  (constrictions,  cervical  mucus)  placed  in  the  canal  by  nature  for 
the  purpose  of  protecting  the  deeper  organs. 

The  strength  of  this  natural  resistance  to  the  spread  of  the  disease  varies 
much  in  different  persons.  In  some  cases  the  gonorrhea  is  well  limited,  ex- 
tending upward  not  at  all  or  only  by  short  steps  at  long  intervals.  In  other 
cases  it  runs  a  rapid  course  from  the  external  genitals  to  the  inmost  recesses 
of  the  genital  canal. 

This  marked  variability  in  the  course  of  the  disease  is  easily  demon- 
strated by  closely  questioning  patients  who  give  a  history  of  gonorrhea  some 
months  or  years  before. 

The  favorite  time  for  extension  to  the  endometrium  and  Fallopian  tubes, 
is  during  the  last  day  or  two  of  menstruation  and  the  first  few  days  fol- 
lowing menstruation. 

No  measure  of  treatment  should  be  employed  that  interferes  with  the 
natural  protective  influences. 

One  point  of  particular  importance,  is  to  be  very  careful  not  to  carry 
the  infection  any  further  than  it  has  already  extended.  For  example,  the 
examination  and  treatment  should  be  confined  to  the  inflamed  vulvar  sur- 
faces alone,  unless  there  is  positive  evidence   (such  as  a  profuse  discharge) 


442  DISEASES    OF    THE   EXTERNAL    GENITALS   AND   VAGINA 

that  the  trouble  has  extended  past  the  vagmal  entrance.  Likewise  in  vaginal 
gonorrhea,  no  treatment  or  examination  should  extend  past  the  external  os 
of  the  cervix  uteri,  unless  there  is  unmistakable  evidence  that  the  gonor- 
rhea has  extended  into  the  cervical  canal. 

A  second  important  i)oint  is  to  use  no  application  or  instrumentation 
that  will  injuriously  irritate  the  surfaces.  Though  such  a  strong  irritating 
antiseptic  application  may  kill  most  of  the  gonococci  on  the  surface,  it  causes 
so  much  desquamation  and  irritation  of  the  surface  that  it  favors  multipli- 
cation and  penetration  by  the  remaining  gonococci  and  tends  to  cause,  rather 
than  prevent,  extension  of  the  process,  both  into  the  tissues  and  upward 
along  the  surface. 

On  the  other  hand,  when  no  treatment  is  employed,  the  accumulating 
irritating  discharge  and  vast  colonies  of  bacteria  in  the  affected  canal, 
cause  marked  irritation,  and  favor  extension  deeper  into  the  tissues  and  up- 
ward along  the  canal. 

The  best  results  are  achieved  in  most  acute  and  subacute  eases  by  a  pro- 
gram about  as  follows : 

1.  Office  Applications.  If  inspection  shows  that  the  process  is  appar- 
ently confined  to  the  vulva  (including  meatus  urinarius,  and  ducts  of  the 
vulvo-vaginal  glands)  be  very  careful  not  to  carry  the  examining  finger  or 
the  applicator  or  other  instrument  past  the  hymen  or  hymen-remnants.  Hav- 
ing secured  the  required  specimen  for  microscopic  examination,  the  parts 
are  cleansed  and  the  affected  surfaces  painted  over  with  a  25%  solution  of 
argyrol  or  a  2%  to  5%  solution  of  protargol.  The  application  is  made  with  a 
small  cotton  ball  (the  size  of  a  bean)  caught  in  the  end  of  the  dressing  forceps 
and  dipped  into  a  small  amount  of  the  solution  poured  out  into  a  medicine 
glass.  Or  a  cotton-'wi'apped  applicator  may  be  used.  Silver  nitrate  solu- 
tion (1%  to  5%). does  very  well,  but  is  rather  painful,  and  the  discoloration 
it  causes  on  the  clothing  and  fingers  is  not  removed  by  washing. 

After  a  free  application  of  the  medicine  has  been  made,  the  surfaces  are 
dried  and  some  drying  antiseptic  powder  dusted  in.  The  author  uses  xero- 
form  and  boric  acid  (1  to  3)  and  finds  it  very  satisfactory,  and  without  the 
odor  that  attaches  to  iodoform.  Most  any  non-irritating  antiseptic  powder 
will  answer  the  purpose.  If  it  is  found  that  the  patient  experiences  more 
smarting  and  burning  after  this  drying  of  the  surface,  the  powder  may  be 
left  off  the  next  time. 

A  large  piece  of  absorbent  cotton  is  applied  to  cover  the  vulva,  the 
inner  portion  being  so  disposed  as  to  lie  between  the  inflamed  surfaces,  to 
keep  them  apart  and  absorb  the  discharge.  The  cotton  is  held  in  place  by  a 
T-bandage. 

If  the  examination  shows  that  the  process  has  extended  up  into  the 
vagina  and  the  tenderness  has  subsided  so  that  the  speculum  may  be  used 
without  pain,  the  speculum  is  introduced  and  the  affected  areas    (usually, 


TREATMENT    OF    GONORRHEA  443 

ill  the  primary  acute  attack,  the  entire  vaginal  wall  and  vaginal  surface  of 
cervix)  are  painted  with  the  25%  argyrol  or  one  of  the  other  solutions  above 
mentioned.  The  vagina  is  then  dried  and  the  non-irritating  antiseptic  powder 
dusted  in. 

The  vulva  is  treated  in  the  same  way  and  covered  with  absorbent  cot- 
ton, as  above  described. 

2.  Prescriptions.  Give  the  patient  a  prescription  for  a  concentrated  anti- 
septic solution  for  making  up  an  antiseptic  wash  or  douche  solution  as  re- 
quired.    The  author  usually  gives  the  regular  bichloride  douche  solution. 

The  bichloride  tablets  are  cheaper,  but  they  are  dangerous  to  have  about 
a  house  where  children  live  or  may  come  visiting. 

If  the  patient  is  nervous  and  sleepless  and  upset  by  the  trouble,  give  a 
prescription  for  some  sedative  solution,  such  as  the  sodium  bromide  solu- 
tion with  instructions  to  take  at  8  and  10  p.  m.  and  8  a.  m.,  and  repeat  after 
three  hours,  when  very  restless. 

If  the  patient  is  not  very  nervous,  but  complains  of  marked  bladder 
irritability  (frequently  painful  urination)  give  the  hyoscyamus  and  potas- 
sium citrate  mixture  instead  of  the  bromide. 

If  there  is  neither  marked  bladder  irritability  nor  decided  nervous  dis- 
turbance requiring  a  prescription,  it  is  well  to  give  the  patient  some  one  of 
the  internal  urinary  antiseptics,  which  tend  to  prevent  extension  of  the 
trouble  along  the  urethra  and  tend  also  to  allay  discomfort  there,  such  as 
hexamethylamin  (urotropin  or  cystogen).  Tell  her  to  get  also  a  pound  of 
surgical  absorbent  cotton. 

3.  Instructions.     Give  the  patient  the  following  instructions : 

a.  When  you  reach  home,  lie  do"wn  and  stay  in  bed  practically  all  the 
time,  as  long  as  there  are  any  acute  symptoms  (pain,  burning,  bladder  irri- 
tability). It  is  especially  important  to  be  quiet  in  bed  during  menstrua- 
tion and  for  some  days  afterward. 

b.  Keep  the  bowels  well  open  every  day,  as  that  tends  to  diminish  the 
pelvic  congestion.  Free  bowel  movements  should  be  secured  by  internal 
laxatives.  No  enema  is  permissible,  ordinarily,  because  of  the  danger  of 
carrying  the  infection  into  the  rectum.  For  the  same  reason,  rectal  sup- 
positories should  not  be  used. 

c.  Keep  the  parts  covered  with  a  large  piece  of  absorbent  cotton,  held 
in  place  by  a  bandage  or  napkin  such  as  is  used  during  menstruation.  As 
often  as  the  inner  surface  of  the  cotton  is  soiled,  it  should  be  removed  and  a 
fresh  piece  applied.  This  removes  the  discharge  from  the  inflamed  sur- 
faces and  prevents  the  irritation  that  would  result  from  its  accumulation 
there.  More  important  still,  it  prevents  general  contamination  of  the  cloth- 
ing and  hands  and  other  surfaces  by  the  infective  discharge.  Each  time, 
after  the  patient  changes  the  dressing,  she  should  immediately  cleanse  her 
hands  with  soap  and  Avater  and  then  in  the  antiseptic  solution  which  she 
uses  for  a  douche. 


444  DISEASES    OF    THE   EXTERNAL   GENITALS   AND   VAGINA 

In  explaining  to  the  patient  the  necessity  of  keeping  the  infected  sur- 
faces covered  vrith  cotton,  and  of  changing  the  cotton  often  and  of  washing 
the  hands  veil  afterward  each  time,  take  particular  care  to  arouse  no  suspicion 
that  might  lead  to  domestic  infelicity. 

Your  work  is  to  lessen  suffering,  not  to  cause  it.  If  the  patient  should 
become  apprised  of  the  fact  that  her  husband  has  been  untrue  to  her  and 
in  addition  has  brought  to  her  a  loathsome  disease,  her  suffering  Avould  be 
far  greater  than  any  physical  distress  that  might  result  from  the  disease, 
even  though  it  goes  on  to  pelvic  suppuration  requiring  operation. 

The  author  has  no  sympathy  for  the  man  who  commits  adultery  and 
brings  a  disease  of  the  women  of  the  streets  to  the  pure  woman  whom  he 
has  promised  to  love,  cherish  and  protect.  He  reaps  his  rcAvard  in  due  time. 
It  is  not  to  protect  him  that  the  need  of  caution  is  mentioned,  but  to  pro- 
tect the  woman  herself  from  unnecessary  suffering.  This  can  usually  be  ac- 
complished by  the  exercise  of  a  little  tact.  To  the  patient's  question,  ''What 
is  the  trouble  1"  a  good  answer  is  ''Inflammation."  Then  pass  quickly  to  the 
directions  concerning  treatment.  At  a  convenient  time  mention  that  the  dis- 
charge is  irritating  and  that  she  must  be  careful  that  none  be  carried  to 
the  eyes  on  contaminated  fingers  or  serious  inflammation  of  the  eyes  may 
result.  The  patient  usually  becomes  so  interested  in  the  treatment  that  she 
forgets  to  inquire  as  to  the  cause  of  inflammation.  However,  if  she  asks,  as 
they  sometimes  do  even  when  having  no  suspicion,  "Doctor,  what  is  the 
cause  of  inflammation?"  the  usual  reply  is:  "Inflammation  is  due  to  various 
causes,"  in  a  tone  that  shows  that  the  physician  has  neither  the  time  nor 
the  inclination  to  give  the  patient  a  course  in  medicine  in  order  that  she 
may  understand  all  the  details  about  inflammation.  This  rarely  fails  to 
stop  troublesome  questions.  Of  course,  some  patients  are  so  suspicious  that 
they  will  not  stop  questioning  until  they  have  got  all  the  information 
they  can  possibly  secure,  Avhile  others  are  well  aware  of  the  nature  of  the 
trouble  and  question  the  physician  out  of  curiosity  or  to  see  if  he  has  a  grasp 
of  the  situation.  With  such,  much  time  must  not  be  wasted.  Do  not  tell 
them  the  exact  nature  of  the  trouble,  when  you  do  not  think  best  to  do  so, 
neither  must  you  tell  them  an  untruth.  When  pressed  too  closely,  simply 
remind  them  that  their  principal  desire  is  to  get  well,  that  they  have  come 
for  treatment,  that  they  receive  the  treatment,  and  have  been  given  all  the 
information  necessary  to  treatment.  If  not  satisfled  with  that  they  may 
go  elsewhere. 

Of  course,  some  patients  know  or  will  probably  find  out  in  a  short  time 
the  nature  of  the  trouble.  But  it  is  preferable  that  they  find  out  from  some 
other  source,  if  at  all.  Your  imparting  the  information,  or  confirming  that 
imparted  by  some  of  their  anxious  friends,  will  do  no  good  and  may  do 
much  harm. 

d.  Use  the  weak  antiseptic  wash  every  3  to  6  hours,  depending  on  the 
amount  of  discharge.     If  the  vagina  also  is  involved,  have  the  patient,  in 


TREATMENT   OF    GONORRHEA  .  445 

addition  to  the  external  Avashing,  take  a  douche  of  the  weak  bichloride  solu- 
tion about  every  eight  hours.  The  internal  remedies  mentioned  are  to  be 
used  as  indicated  by  the  special  symptoms  in  the  case. 

e.  The  patient  should  be  directed  to  return  for  local  treatment  every 
second  or  third  day,  provided  she  can  do  so  without  aggravating  the  in- 
flammation. 

If  there  is  much  discomfort  in  walking  or  if  the  patient  must  come  a 
long  way  to  reach  the  offl.ce,  she  will  experience  more  benefit  from  remaining 
quiet  at  home  and  foUoAAdng  the  directions  already  given  for  the  treatment 
there. 

4.  When  the  patient  can  come  to  the  office .  without  detriment,  treat  the 
affected  surface  just  as  described  for  the  first  visit.  Such  treatment,  so  ap- 
plied as  to  cause  no  irritation,  seems  to  aid  materially  in  diminishing  the 
patient's  discomfort  and  in  hastening  the  subsidence  of  the  inflammation. 
The  treatment  is  repeated  every  second  or  third  day  until  all  inflammation 
has  disappeared  from  the  affected  surfaces,  the  intervals  being  gradually 
lengthened  as  improvement  takes  place. 

It  is  not  advisable  during  this  first  part  of  the  attack,  that  is,  in  the  first 
two  or  three  weeks,  to  swab  out  the  lower  part  of  the  urethra  or  of  the 
cervical  canal,  or  to  inject  medicine  into  Skene's  glands  or  into  the  ducts  of 
the  vulvo-vaginal  glands.  Such  treatment  is  likely  to  carry  the  inflamma- 
tion further  in  than  it  might  otherwise  go,  and  may  make  permanent  an 
infection  which  nature  would  throw  off  if  given  a  little  time.  If  inflamma- 
tion in  any  of  these  situations  persists  into  the  chronic  stage,  then  they 
require  particular  treatment. 

In  those  very  severe  acute  cases  where  the  patient  suffers  a  great  deal 
from  the  burning,  itching,  smarting  and  throbbing  pain,  and  the  trouble  is  in- 
creased when  the  patient  stands,  she  should  be  put  to  bed  and  kept  there 
until  the  most  acute  symptoms  have  disappeared.  In  the  meantime,  she 
should  follow  the  directions  given  for  the  treatment  at  home.  If  the  weak 
bichloride  solution  seems  to  cause  any  irritation  (it  does  with  some  patients), 
use  a  weak  34%  lysol  solution  or  some  other  antiseptic  in  weak  solution.  The 
potassium  permanganate  douche  is  effective. 

The  principal  effect  of  the  wash  and  douche  is  to  remove  mechanically 
the  irritating  secretion.  It  may  be  used  warm  or  tepid  or  cool,  as  found 
most  agreeable. 

In  cases  where  the  smarting  and  itching  are  marked,  the  25%  argyrol 
may  be  applied  with  the  patient  in  bed,  by  bringing  the  patient  around  in 
the  bed,  with  each  foot  on  a  chair,  as  for  a  vaginal  examination  (Fig.  123).  If 
neither  the  cleansing  nor  the  argyrol  applications  relieve  the  smarting  about 
the  external  genitals,  give  the  patient  a  prescription  for  the  '4ead  and 
opium  wash"  and  direct  her  to  use  it  freely,  dabbing  it  on  with  cotton  balls 
frequently  enough  to  keep  the  surfaces  moist  with  it. 


446  DISEASES    OP    THE   EXTERNAL    GENITALS   AND   VAGINA 

111  some  of  these  severe  cases,  a  hot  sitz-bath  every  4  to  6  hours  gives 
considerable  relief. 

Treatment  of  Chronic  Gonorrhea 

A  chronic  gonorrheal  discharge  is  due  to  persistence  of  the  specific  inflam- 
mation in  one  or  more  isolated  areas.  When  such  a  discharge  persists  after 
the  inflamed  surfaces  generally  have  returned  to  normal  (i.e.,  after  3  to  6 
weeks,  depending  on  the  severity  of  the  inflammation),  make  careful  search 
for  its  exact  source.  The  situations  in  which  the  inflammation  is  likely  to 
persist  are  the: 

Vulvo-vaginal  glands  or  ducts. 
Skene's  glands,  in  the  urethra. 
Upper  end  of  vagina. 
Cervix  uteri. 
Corpus  uteri. 

In  Vulvo-vaginal  Glands  or  Ducts.  Persistence  of  the  gonorrheal  inflam- 
mation in  the  duct  of  a  vulvo-vaginal  gland,  is  indicated  by  reddening  about 
the  mouth  of  the  duct  and  by  a  discharge  from  it,  a  drop  of  which  may 
usually  be  pressed  out.  Microscopic  examination  of  this  discharge  usually 
shows  gonococei  in  abundance,  though  in  some  old  cases  they  may  disap- 
pear temporarily. 

The  treatment  for  this  condition  is  to  make  an  application  of  25%  argyrol 
or  5%  to  10%  protargol  about  every  other  day. 

The  acute  and  subacute  symptoms  have  all  disappeared,  and  the  patient 
may  now  come  to  the  office  as  often  as  necessary,  without  any  probability  of 
disturbance  from  the  exercise. 

The  application  of  argyrol  or  protargol  to  the  interior  of  the  duct  is 
made  by  a  fine  applicator  with  a  thin  cotton  wrapping. 

The  mouth  of  the  duct  should  be  opened  so  it  will  easily  admit  the  ap- 
plicator carrying  the  medicine.  Occasionally  the  necessary  widening  may 
be  effected  by  simple  dilatation.  Usually,  however,  it  will  be  necessary  to 
incise  the  opening  so  as  to  give  a  wide  entrance, 

A  small  piece  of  cotton  soaked  in  20%  cocaine  solution  is  laid  over  the 
area,  a  small  amount  being  pushed  into  the  opening  a  short  distance.  Leave 
this  in  place  5  minutes.  Then  introduce  into  the  duct  the  sharp  point  of  a 
slender  bistoury  and  make  a  cut  outward  or  dowuAvard  from  an  eighth  to  a 
quarter  of  an  inch.  If  the  external  application  of  cocaine  does  not  obtund 
the  sensibility,  as  tested  by  the  bistoury  point  before  cutting,  inject  some 
Yofo  cocaine  solution  or  some  of  the  Schleich  solution  No.  2  into  the  area 
to  be  incised. 

When  the  duct  is  thus  made  accessible,  make  a  thorough  application  to 


TREATMENT   OF    GONORRHEA  447 

its  interior,  taking  care,  however,  not  to  carry  the  infection  into  the  gland 
if  it  has  not  already  got  there. 

The  other  duct  if  involved  is  treated  the  same  way. 

If  the  inflammation  subsides,  the  applications  are  kept  up  until  all  dis- 
charge ceases,  lengthening  the  intervals  as  improvement  takes  place. 

There  are  usually  other  points,  as  in  Skene's  glands,  or  in  the  cervix,  that 
require  treatment  at  the  same  time. 

If  no  decided  improvement  appears  after  a  few  applications,  the  af- 
fected duct  with  its  gland  needs  to  be  extirioated.  Also,  if  the  gland  shows 
evidence  of  chronic  involvement  (firm  nodule  in  that  situation)  it  requires 
extirpation,  for  as  long  as  it  remains,  it  prevents  complete  cure  and  the  dis- 
charge from  it  is  a. source  of  danger. 

If  an  abscess  forms  in  the  gland,  it  is  allowed  to  develop  until  the  gland 
is  probably  destroyed  and  the  collection  is  near  the  surface,  covered  only  by 
a  thin  wall  of  tissue.    It  is  then  opened  freely. 

If  the  abscess  is  well  developed  so  that  all  sej)ta  are  destroyed  and  the 
recesses  form  part  of  the  main  cavity,  there  may  be  complete  healing  after- 
Avard  and  an  end  of  the  trouble.  If  a  second  abscess  forms  later,  however,  that 
means  that  portions  of  the  infected  gland  remain,  and  in  such  a  case,  all  the 
involved  indurated  tissue  should  be  extirpated,  after  the  abscess  has  been 
drained  and  all  acute  symptoms  are  gone.  When  it  is  necessary  to  wait  a 
few  days  for  an  abscess  to  get  in  good  condition  for  opening,  the  patient  is 
directed  to  stay  in  bed  and  make  hot  applications  of  absorbent  cotton  wrung 
out  of  very  hot  water  or  weak  antiseptic  solution,  and  covered  with  oil  silk. 
As  a  rule  the  pain  is  not  severe  until  the  abscess  is  ready  to  open  or  about 
ready  to  break. 

Then  the  patient  may  come  to  the  office,  or,  if  movement  is  very  pain- 
ful, it  may  be  opened  at  her  home. 

In  Skene's  Glands.  When  the  gonorrheal  inflammation  invades  these 
periurethral  ducts  it  may  remain  there  indefinitely,  causing  symptoms  of 
chronic  urethritis  or  chronic  cystitis  and  a  persistent  infective  discharge. 
There  is  redness  about  the  urethra  and  pouting  outward  of  the  swollen 
urethral  mucosa.  If  the  patient  has  passed  through  parturition,  the  opening 
of  the  duct  on  each  side  may  usually  be  seen  by  rolling  out  the  urethral 
mucosa  (Fig.  44).  If  the  duct  is  open  a  drop  of  pus  may  be  pressed  from  it. 
If  the  duct  is  closed,  a  small  abscess  forms  in  it. 

To  treat  these  conditions,  apply  a  pledget  of  cotton  soaked  in  a  20% 
solution  of  cocaine,  pushing  a  part  of  it  a  short  distance  into  the  urethra. 
Leave  this  in  place  five  minutes  and  then  proceed  as  follows : . 

If  the  duct  is  open,  inject  a  25%  solution  of  argyrol  into  it  with  a  hypo- 
dermic syringe.  Use  a  needle  the  point  of  which  has  been  filed  round  and 
smooth,  so  it  will  easily  pass  into  the  duct  without  penetrating  the  wall. 
Fill  the  duct  with  the  solution  so  that  it  comes  in  contact  with  all  the  recesses. 
This  is  simply  a  small  duct.     There  is  no  gland  back  of  it,  into  which  infec- 


448  DISEASES    OF    THE   EXTERNAL    GENITALS    AND   VAGINA 

tion  may  be  carried,  so  the  medicine  may  be  injected  freely.  This  injection 
is  repeated  every  few  days,  at  the  same  time  that  other  infected  structures 
are  treated. 

If  the  inflammation  persists  in  spite  of  this,  then  dilate  the  urethra  and 
slit  open  the  ducts  and  treat  their  interior  directly  with  the  solutions  al- 
ready mentioned.  Some  prefer  to  make  very  strong  applications  to  the 
ducts  after  they  are  slit  open,  for  example,  carbolic  acid  and  tincture  of 
iodine,  half  and  half.  The  slitting  open  and  treatment  of  Skene's  ducts 
may  be  done  under  cocaine  anesthesia.  In  some  cases  there  are  other  chroni- 
cally infected  areas  that  need  painful  treatment  requiring  a  general  anes- 
thetic (extirpation  of  a  vulvo-vaginal  gland  or  dilatation  and  curetment  of  the 
uterus  or  excision  of  infected  cervical  tissue),  and  the  urethral  duets  may  be 
taken  care  of  at  the  same  time. 

In  Vaginal  Vault.  Persistent  inflammation  at  the  vaginal  A-ault  is  due 
usually  to  an  irritating  and  infective  discharge  from  the  cervical  canal.  The 
chronic  uterine  infection  may  be  located  in  the  cervix  or  in  the  body  of  the 
uterus.  The  treatment  of  these  conditions  will  be  found  under  inflammatory 
diseases  of  the  uterus  (see  Chapter  vi). 

Occasionally  there  will  be  persisting  inflammation  of  the  vaginal  vault 
without  involvement  of  the  cervical  canal,  the  cervical  discharge  being  prac- 
tically clear  mucus,  though  considerably  increased  in  amount  by  the  hyper- 
emia. 

Whether  the  inflammation  at  the  vaginal  vault  exists  alone  or  is  second- 
ary to  chronic  gonorrheal  endocervicitis  or  endometritis,  it  requires  treat- 
ment. There  are  two  methods  of  treatment — the  glycerine-tampon  treatment 
and  the  dry  treatment. 

1.  Glycerine-tampon  Treatment.  Introduce  the  speculum,  expose  the 
cervix  and  vaginal  vault,  cleanse  the  surfaces  with  an  antiseptic  solution, 
and  treat  the  interior  of  the  cervix  if  it  requires  treatment.  Cleanse  the 
surfaces  again  and  dry  them  and  then  apply  a  25%  argyrol  or  10%  pro- 
targol  or  10%  silver  nitrate  solution  to  the  vaginal  vault  and  vaginal  surface 
of  the  cervix. 

Wipe  out  the  excess  of  fluid  and  then  apply  an  absorbent-cotton  tampon 
with  the  inner  end  soaked  in  10%  ichthyol- glycerine  or  10%  protargol-giy- 
cerine.  It  is  supposed  that  the  glycerine,  by  its  hygroscopic  action,  helps  to 
work  the  deeper  gonococci  towards  the  surface,  where  they  may  be  acted 
on  by  the  antiseptic. 

The  tampon  should  be  packed  in  rather  firmly,  so  as  to  stretch  the 
vaginal  wall.  This  firm  packing  of  the  vaginal  vault,  smooths  out  the 
wrinkles  and  brings  the  gonococci  nearer  the  surface.  It  has  much  the 
same  effect  that  the  passage  of  a  large-sized  sound  has  in  chronic  gonorrheal 
urethritis  in  the  male. 

This  firm  tamponade  of  the  upper  part  of  the  vagina  is  best  applied  with 
the  patient  in  Sims'  posture  or  in  the  knee-chest  posture. 


TREATMENT    OF    GONORRHEA  449 

If  there  is  much  uterine  discharge,  this  tampon  must  be  removed  by  the 
patient  in  8  to  12  hours,  and  the  antiseptic  douches  continued  until  she  re- 
turns in  two  or  three  days  for  the  next  treament. 

If  the  uterine  discharge  is  slight,  the  tampon  may  be  left  in  24  hours, 
and  then   removed    and   the    douches    continued   until   the   next   treatment. 

If  there  is  decided  infiltration  and  thickening  of  the  vaginal  wall,  it 
may  be  advantageous  to  use  25%  ichthyol-giycerine  on  the  tampon,  for  a  few 
times.  This  causes  desquamation  of  the  superficial  layers  of  the  vaginal 
mucosa,  thus  bringing  the  medicine  closer  to  the  bacteria,  and  permitting 
better  penetration  of  the  affected  tissues  by  the  medicine. 

2.  Dry  Treatment.  Expose  the  vaginal  vault  with  the  speculum,  cleanse 
the  surfaces,  treat  the  interior  of  the  cervix,  ■  if  it  needs  treatment,  and 
cleanse  the  surfaces  again.  Dry  the  vault  well  and  apply  the  25%  argyrol 
or  10%  protargol  or  10%  silver  nitrate  to  the  affected  surfaces. 

Apply  this  thoroughly  and  let  it  soak  into  all  the  fine  depressions.  Then 
dry  the  wall  again  and  dust  in  a  large  amount  of  some  astringent-antiseptic 
drying  powder.  The  author  uses  a  powder  composed  of  tannic  acid  (1  part), 
xeroform  (1  part)  and  boric  acid  (3  parts).  This  is  put  in  freely  with  the 
powder-blower. 

For  throwing  powders  in  large  quantity  into  the  upper  part  of  the 
vagina,  the  author  finds  the  ordinary  8-ounce  Politzer-bag  very  convenient. 
The  tip  is  unscrewed,  the  bag  filled  about  one-third  full  of  the  powder  and 
the  tip  screwed  on  again.  Now,  by  tipping  the  bag,  the  powder  runs  into 
the  tube,  and  little  or  much,  as  desired,  may  be  thrown  to  the  top  of  the 
vagina.  If  the  tube  clogs  with  powder,  turn  the  tube  end  up  and  tap  the 
bottom  of  the  bag  on  some  solid  surface.  This  jars  the  powder  out  of  the 
tube  and  clears  it  for  use.  Of  course,  if  the  powder  gets  damp,  then  the 
tube  must  be  cleansed  with  an  applicator,  and  possibly  the  bag  emptied  and 
fresh  powder  put  in. 

After  the  powder  has  been  dusted  into  the  vagina,  then  a  good-sized 
cotton  or  wool  tampon  is  spread  at  its  upper  end  and  a  quantity  of  the  same 
powder  placed  in  the  depression,  and  the  tampon  carried  to  the  vaginal  vault. 
One  or  two  smaller  ones  may  be  packed  below  it  to  hold  it  well  in  place. 
This  constitutes  a  "dry  treatment." 

If  there  is  but  little  discharge  from  the  cervix,  this  tampon  may  be  left 
in  place  for  two  days,  the  patient  returning  then  to  have  it  renewed.  In 
such  a  case  the  powder  should  be  dusted  in  freely  between  the  tampons,  in 
order  to  have  a  strong  antiseptic  effect  and  prevent  decomposition  during 
the  two  days  that  the  tamponade  is  in  place. 

"When  the  patient  returns  the  tamponade  is  removed,  the  vagina  thor- 
oughly cleansed  and  another  dry  treatment  given. 

These  are  continued  until  the  vaginal  wall  has  apparently  returned  to  a 
normal  condition,  then  the  treatment  is  stopped  and  the  case  watched. 

Examinations,  to  determine  the  amount  of  discharge  and  the  condition 


450  DISEASES    OF    THE   EXTERNAL    GENITALS    AND   VAGINA 

of  the  vaginal  vault,  are  made  at  intervals  of  a  week  or  so,  and  also  micro- 
scopic tests  of  any  discharge  that  appears. 

In  a  case  vhere  there  is  much  uterine  discharge,  the  tamponade  must  be 
removed  in  24  hours  and  antiseptic  douches  continued  until  the  patient  re- 
turns for  the  next  treatment.  In  such  a  case  the  tampons  must  be  arranged 
with  strings  so  that  the  patient  may  remove  them  easily.  This  modified-  dry 
treatment  is  very  useful  in  cases  where  an  endocervicitis  is  being  treated  at 
the  same  time.  However,  in  the  cases  of  persistent  uterine  discharge,  it  is 
useless  to  continue  this  treatment  except  as  a  palliative  measure.  As  long  as 
the  infective  uterine  discharge  continues,  there  will  necessarily  be  irritation 
of  the  vaginal  vault.  In  such  a  case,  effective  treatment  for  the  chronic 
uterine  inflammation  is  the  important  matter. 

Serum  and  Vaccine  Treatment.  Outside  of  the  local  treatment,  described 
above,  in  the  last  few  years  a  general  treatment  with  animal  serums,  and 
especially  with  vaccines,  has  been  advocated  by  various  writers.  They  have 
proved  only  partially  successful.  Practically  no  effect  is  obtained  in  the 
chronic  cases  in  which  the  gonorrheal  infection  has  led  to  pronounced  in- 
flammatory changes  in  the  pelvis.  The  best  results  are  seen  with  vaccines 
in  cases  of  gonorrheal  arthritis  and  in  the  gonorrheal  vulvo-vaginitis  of  chil- 
dren. 

Only  rarely  autogenous  vaccines  are  prepared  from  gonococci  cultured 
from  the  patient's  cervical  or  urethral  discharge.  More  commonly  stock  vac- 
cines are  employed,  prepared  from  mixed  cultures,  as  supplied  to  the  trade  by 
various  reliable  manufacturers.  These  vaccines  are  administered  subcuta- 
neously,  the  dosage  being  dependent  upon  the  concentration  of  the  prepara- 
tion. In  general  the  treatment  is  begun  with  a  first  injection  of  five  million 
bacteria,  the  dosage  increasing,  according  to  reaction,  to  twenty  million,  usu- 
ally four  to  five  injections  being  given  in  an  interval  of  five  to  seven  days. 

In  Cervix  and  Corpus  Uteri.  Gonorrheal  inflannnation  of  the  uterus 
is  considered  in  Chapter  vi. 

Gonorrhea  in  Children 

Gonorrheal  inflammation  in  female  infants  and  children  is  more  frequent 
than  is  generally  supposed.  In  any  case  of.  severe  or  persisting  discharge 
from  the  vulva,  microscopic  examination  should  be  made  in  order  to  estab- 
lish the  presence  or  absence  of  gonorrhea. 

In  infants  and  children  the  process  is  more  likely  to  be  confined  to  the 
external  genitals,  for  usually  there  has  been  no  penetration  into  the  vagina 
by  the  infecting  agent.  Some  of  these  cases  are  due  to  rape,  but  probably 
the  most  of  them  are  due  to  accidental  contamination  from  soiled  clothing 
or  closet-seat  or  from  the  fingers  of  the  mother  or  attendant. 

The  principles  of  treatment  are  the  same  as  for  the  adult — namely,  fre- 
quent cleansing,  the  use  of  a  reliable  goiiocide  preparation  and  the  exercise 


SIMPLE   VULVITIS  451 

of  care  not  to  carry  the  infection  higher  than  the  surfaces  already  involved. 
Particular  care  should  be  taken  to  instruct  the  mother  as  to  frequent 
cleansing  of  the  parts  with  warm  water  or  with  a  mild  antiseptic  wash  and 
as  to  keeping  the  parts  covered  to  prevent  contamination  of  the  clothing  by 
the -discharge.  Argyrol  is  an  excellent  gonocide  for  use  in  these  cases,  as  it 
causes  little  or  no  pain.  Start  with  a  weak  solution  (5%)  and  advance  to 
the  stronger  (25%)  as  the  patient  becomes  accustomed  to  it.  If  the  vagina 
is  involved,  the  washing  out,  and  also  the  application  of  the  gonocide,  may 
be  carried  out  through  a  small  soft  rubber  catheter. 

SIMPLE  VULVITIS 

Simple  vulvitis  is  superficial  inflammation  of  the  external  genitals  due 
to  irritation  or  to  infection  with  ordinary  pus  germs.  Sometimes  it  takes  the 
form  of  scalding  or  chafing. 

Etiology 

The  predisposing  causes  of  simple  vulvitis  are  poor  general  health,  and 
local  conditions  which  cause  pelvic  congestion,  for  example,  pregnancy  and 
pelvic  tumors. 

The  exciting  causes  are  as  follows : 

1.  An  Irritating'  Vaginal  Discharge.  In  the  various  forms  of  acute  vag- 
initis and  acute  endometritis,  the  discharge  alone  may  be  sufficiently  irritat- 
ing to  cause  pronounced  vulvitis. 

-  In  chronic  vaginal  discharge  there  may  be  considerable  itching,  and  the 
consequent  scratching  and  friction  is  principally  responsible  for  the  infiam- 
mation.  In  children  this  is  a  very  frequent  cause  of  troublesome  and  per- 
sistent vulvitis. 

2.  Irritating  Urine.  Diabetic  urine  may  cause  vulvar  irritation  with 
resulting  chronic  inflammation  and  thickening  of  the  tissues.  In  this  condition 
there  is  a  brawny  induration  with  sometimes  considerable  enlargement. 
Other  substances  in  the  urine,  such  as  pus,  or  high  concentration  of  the  urine, 
may  cause  irritation  leading  to  scratching  and  consequent  vulvitis. 

v3.  Parasitic  Affections.  In  pediculosis  pubis,  the  pediculi  are  located 
about  the  pubic  hairs,  where  they  cause  much  itching  and  irritation  and  may 
lead  to  vulvitis.  Ascarides  (the  thread-worm. from  the  rectum)  may  cause 
severe  scratching  and  vulvitis.  In  persistent  vulvitis  in  children  without 
apparent  cause,  the  stools  should  be  examined  for  the  presence  of  the  thread- 
worm or  "seat-worm"  as  it  is  sometimes  called. 

4.  Masturbation.  Friction  from  masturbation  may  lead  to  inflammation 
of"  the  external  genitals.  There  is  usually  some  irritant  that  first  causes 
scratching  and  the  masturbation  is  an  after-development.  In  children  this 
may  lead  to  severe  vulvitis.  In  older  persons  it  more  frequently  causes 
simply  hypertrophy  of  the  labia  minora. 


452  DISEASES    OF    THE   EXTERNAL    GENITALS    AND    VAGINA 

5.  Lack  of  Cleanliness.  In  exceptional  cases,  this  alone  may  act  as  a 
cause,  but  usually  it  serves  only  to  aggravate  the  irritation  due  to  some  of  the 
other  causes  mentioned. 

6.  Acute  Exanthemata.  In  eruptive  diseases,  the  same  process  that  af- 
fects the  skin  elsewhere  may  aifect  the  vulva  where,  on  account  of  the  local 
heat  and  moisture,  there  may  result  much  irritation  and  inflammation. 

Pathology 

In  acute  vulvitis  there  are  the  usual  signs  of  inflammation,  the  intensity 
of  the  signs  depending  on  the  severity  of  the  process.  If  very  severe  or  if 
there  has  been  much  scratching,  there  may  be  denuded  areas  discharging 
serum  or  pus.  If  the  inflammation  has  been  present  a  long  time  and  is 
consequently  in  the  chronic  stage,  there  is  cellular  infiltration  of  the  tissues, 
Mdth  induration  and  discoloration  and  frequently  considerable  hypertrophy. 

Symptoms  and  Diagnosis 

The  symptoms  are  itching  and  burning  and  heat  about  the  genitals,  with 
redness,  swelling  and  discharge.  There  may  be  many  abrasions  due  to  scratch- 
ing, and  also  small  ulcers  from  the  same  cause.  Often  there  is  burning  on 
urination  and  increased  frequency  of  urination.  In  the  chronic  stage,  the 
secondary  conditions  just  mentioned  under  pathology  are  noticeable. 

Gonorrheal  vulvitis  is  distinguished  by  the  characteristics  mentioned  under 
gonorrhea.  In  this  connection  it  must  be  kept  in  mind  that  simple  vul- 
vitis may,  in  exceptional  cases,  lead  to  simple  urethritis  in  the  patient  and 
even  in  her  husband. 

Treatment 

After  determining  certainly  that  gonorrhea  is  not  present  (for  it  re- 
quires more  active  measures)  proceed  with  the  treatment  of  the  simple  vul- 
vitis as  follows: 

1.  Secure  Cleanliness.  The  parts  should  be  washed  several  times  daily 
with  a  carbolic  solution  or  other  mild  antiseptic  solution. 

]^     Acid  Carbolici 

Glycerini,  aa  90  c.c. 

Sig. :     Teaspoonful  to  a  pint  of  water.     Use  as  a  wash  several  times 
daily. 

Small  balls  of  absorbent  cotton  are  very  convenient  for  applying  the 
wash  to  the  surface  and  for  removing  the  discharge.  This  keeps  the  parts 
clean  and  to  some  extent  relieves  the  itching.  After  each  washing,  the  parts 
should  be  thoroughly  dried  and  then  kept  dry  by  being  dusted  freely  with 
some  drying  powder,  for  example,  stearate  of  zinc  or  bismuth  subgallate  or 
bismuth   subnitrate   or  boric   acid   or   equal  parts   of   bismuth  subcarbonate 


TREATMENT    OF    SIMPLE    VULVITIS  453 

and  prepared  chalk  or  one  of  the  nnmerons  preparations  of  "talcum  powder" 
prepared  for  toilet  nse.  The  inflamed  surfaces  should  be  kept  separated  by 
a  pledget  of  cotton  placed  between  them  and  renewed  as  soon  as  it  becomes 
wet  with  the  discharge. 

2.  Remove  the  Cause.  If  the  vulvitis  is  due  to  a  discharge  from  vaginal 
or  uterine  disease,  the  nature  of  the  disease  must  be  determined  and  ap- 
propriate treatment,  as  described  elsewhere,  employed.  In  the  case  of 
uterine  disease,  if  the  discharge  can  not  be  checked  at  once  it  may  be  kept 
from  irritating  the  vulva  by  tampons  placed  against  the  cervix  and  renewed 
often  enough  to  absorb  the  discharge. 

In  children  there  is  often  what  seems  to  be  simply  loss  of  tone  with 
excessive  secretion,  giving  a  vaginal  discharge.  If  this  condition  does  not 
yield  to  tonic  treatment  and  external  cleansing  measures,  the  treatment  de- 
scribed for  vaginitis  in  children  should  be  employed  (see  page  450). 

If  diabetes  or  other  marked  urinary  disturbance  is  present,  it  will  be 
discovered  in  the  urine  analysis,  and  must  be  given  suitable  treatment.  In 
pediculosis  pubis,  a  few  inunctions  of  oleate  of  mercury  will  kill  the  parasites. 
If  asearides  cause  the  trouble,  give  the  following  enema  every  other  day  until 
the  worms  disappear. 

R     Infus.  quassiae,  120  c.e. 

Sig. :     Four  tablespoonfuls  to  a  pint  of  warm  water.     To  be 
used  as  a  rectal  injection,  as  directed. 

In  masturbation,  remove  all  local  irritation,  keep  the  genitals  cleansed, 
give  bromides  to  diminish  the  irritability  of  the  sexual  center  and,  if  neces- 
sary, appeal  to  the  reason  and  pride  and  fear  of  the  child  or  adult,  as  the 
case  may  be,  to  prevent  the  continuance  of  the  habit. 

3.  Make  Sedative  or  Astringent  Applications.  If  the  inflammation  is 
acute  and  accompanied  by  burning  and  itching,  not  relieved  by  the  cleans- 
ing measures,  the  lead  and  opium  wash  may  be  used.  A  thick  layer  of  ab- 
sorbent cotton,  or  a  soft  cloth,  should  be  soaked  in  this  solution  and  ap- 
plied, to  the  genitals  after  the  cleansing  with  the  carbolic  wash.  The  lead 
and  opium  mixture  may  be  kept  applied  to  the  genitals  as  long  as  the  severe 
burning  and  smarting  are  present.  It  usually  gives  the  desired  relief.  The 
borax  and  opium  wash  is  another  sedative  application  which  is  used  in  the 
same  way.  In  some  cases  it  may  be  necessary  to  apply  cocaine  solution  (4%) 
occasionally,  when  the  irritation  is  most  marked.  A  small  piece  of  absorbent 
cotton  wet  in  the  solution  may  be  rubbed  over  the  inflamed  area  or  applied 
to  them  for  several  minutes.  Continuous  applications  of  cocaine  solution  for 
any  considerable  length  of  time  is  not  advisable  on  account  of  the  danger  of 
absorption. 

In  some  cases  in  which  an  irritating  discharge  from  the  vagina  or  urethra 
can  not  be  stopped,  the  surfaces  coming  in  contact  with  it  may  be  somewhat 


454  DISEASES   OF    THE   EXTERNAL    GENITALS   AND   VAGINA 

protected  by  covering  them  with  zinc  oxide  ointment.  The  ointment  should 
be  applied  each  time  after  the  genitals  have  been  cleansed  with  the  car- 
bolic wash  and  wiped  dry.  The  addition  of  carbolic  acid  (2%  to  5%)  makes 
the  ointment  more  effective  in  relieving  pruritus.  If  this  does  not  give  relief, 
cocaine  (2%  to  10%)  may  be  added. 

Astringent  and  antiseptic  applications  have  a  direct  effect  toward 
diminishing  the  disease,  and  in  most  cases  they  can  be  used  from  the  first. 
If  the  inflammation  is  acute  and  is  accompanied  by  much  discharge,  the  25% 
argyrol  solution  is  beneficial.  It  should  be  applied  carefully  over  all  the 
inflamed  surface  every  second  or  third  or  fourth  day.  The  zinc  sulphate  and 
hydrastis  wash  is  a  good  astringent  application  which  may  be  applied  by  the 
patient. 

.  4.  Internal  Treatment.  Administer  tonics  or  sedatives  or  other  internal 
remedies  as  indicated  by  the  conditions  present.  Patients  in  poor  general 
health  should  have  appropriate  tonic  treatment.  If  there  is  chronic  con- 
stipation, laxatives  should  be  given.  If  there  is  much  urethral  irritation,  as 
indicated  by  frequent  or  painful  urination,  give  the  hyoscyamus  and  potas- 
sium citrate  mixture.  If  the  urine  is  concentrated,  direct  the  patient  to  drink 
an  abundance  of  water.  Lemonade,  not  too  sweet,  is  pleasant  for  a  change 
and  helps  to  make  the  urine  less  irritating. 

If  the  patient  loses  sleep  or  is  made  nervous  by  the  vulvar  irritation,  it 
is  well  to  administer  a  mild  sedative,  such  as  sodium  or  strontium  bromide. 

FOLLICULAR  VULVITIS 

Follicular  vulvitis  occurs  in  adults.  It  is  characterized  by  the  inflamma- 
tion being  confined  principally  to  the  hair  follicles  and  sebaceous  glands,  the 
inflamed  structures  being  represented  by  small  red  papules  scattered  over 
the  labia  (Fig.  199). 

The  causes,  symptoms  and  treatment  are  the  same  as  described  under 
simple  vulvitis.  This  form  of  vulvitis  is  prone  to  become  chronic  and  resist 
treatment,  consequently  it  should  be  treated  vigorously.  The  measures  men- 
tioned under  simple  vulvitis  (acute  and  chronic)  should  be  used.  Also  the 
following  sometimes  gives  relief. 

I^     Liq.   Ferri  Subsulphatis,  4. 

Glycerini,  qs.  ad.,  30. 

Sig. :  Apply  two  or  three  times  daily  with  a  camel's-hair  brush. 

If  pus  forms  in  the  follicles,  they  should  be  evacuated  and  then  washed 
out  with  hydrogen  peroxide.  If  there  is  much  local  inflammation,  hot  com- 
presses wrung  out  of  weak  carbolic  solution  may  give  much  relief. 

Follicular  vulvitis  sometimes  appears  during  pregnancy  and  disappears 
spontaneously  afterward.  In  rare  cases  the  irritation  has  become  so  severe 
that  it  caused  abortion. 


ERYSIPELAS    OF   VULVA  455 

ERYSIPELAS  OF  VULVA 

Erysipelas  of  the  vulva,  like  erysipelas  elsewhere,  is  a  rapidly  spreading 
inflammation  produced  by  the  streptococcus  pyogenes. 

Etiology  and  Pathology.  The  streptococcus  pyogenes,  or  "streptococcus 
erysipelatis, "  as  it  is  sometimes  called,  enters  through  a  crack  or  scratch  or 
abrasion  or  other  open  place  in  the  protecting  epithelium.  Once  within  the 
subepithelial  tissue  it  multiplies  rapidly,  causing  marked  inflammation  with 
a  superficial  parchment-like  induration  of  the  involved  surface.  There  is 
also  inflammatory  edema  of  the  deeper  tissues,  causing  marked  swelling  of 
the  vulva.  The  inflammatory  process  spreads  rapidly  by  a  well  defined 
margin  which  is  red  and  slightly  raised. 

If  the  inflammation  is  intense,  small  vesicles  may  appear  at  various 
places  on  the  surface  and  rupture,  discharging  serum.  The  process  may  ex- 
tend up  onto  the  abdominal  wall  or  out  onto  the  thighs  or  into  the  vagina. 

Symptoms  and  Diagnosis.  In  the  beginning  there  is  usually  a  chill,  fol- 
lowed by  considerable  fever  and  the  general  disturbance  usually  associated 
with  fever.  The  patient  complains  of  heat  and  throbbing  in  the  external 
genitals.  The  fever  continues  and  swelling  of  the  vulva  is  noticed.  The 
patient  then  comes  for  examination,  which  reveals  the  condition  described 
under  pathology.  Later,  pus  may  form.  In  the  diagnosis,  differentiate  from 
scarlatinal  rash  on  vulva,  from  intertrigo,  from  bichloride  rash,  from  cellu- 
litis of  vulva  and  from  hematoma. 

Treatment.  Considerable  relief  will  be  afforded  by  applying  pieces  of 
absorbent  cotton,  or  gauze,  soaked  in  carbolized  olive  oil  (1  to  2%).  The 
exclusion  of  air  seems  to  diminish  the  burning.  The  application  of  an  ice- 
bag  outside  the  oil  dressing,  tends  to  check  the  pruritus  and  the  swelling. 
The  bowels  should  be  moved  well.  If  the  fever  is  high,  it  may  be  reduced 
by  cool  sponge-baths  or  by  some  of  the  reliable  antipyretics.  Quinine  in 
moderate  doses  and  tincture  of  the  chloride  of  iron  in  large  doses  are  time- 
honored  remedies  for  infective  processes.  An  abundance  of  water  should  be 
given  to  help  the  skin  and  kidneys  in  elimination.  If  the  patient  is  weak, 
strychnia  and  other  stimulants  and  tonics  are  indicated. 

In  serious  cases,  some  reliable  antistreptococcus-serum  should  be  used 
freely.  The  author  has  much  confidence  in  Steam's  streptolytic  serum, 
which  he  has  used  with  satisfactory  results  several  times.  In  a  recent  puer- 
peral ease  of  rapidly  spreading  erysipelas  of  the  breast,  with  a  temperature 
of  106°,  the  j)rocess  was  promptly  checked  by  the  free  administration  of  this 
serum.  On  the  other  hand,  in  some  cases,  the  serum  has  no  apparent  effect. 
The  "opsonin"  treatment  elaborated  by  Wright,  promises  to  be  of  benefit 
in  all  infective  processes,  but  it  is  still  in  the  experimental  stage. 

Unguentum  Crede  is  an  excellent  local  application  for  the  inflamed  area. 
Other  local  applications,  found  by  experience  to  be  more  or  less  effective, 


456  DISEASES    OF    THE    EXTERNAL    GEXITALS    AXD    YAGIXA 

are  the  bieliloride  ointment,  carbolized  liquid  vaseline  (o'-^c)  painted  over  tlie 
surface  with,  a  camel 's-liair  brush,  ichthyol  and  glycerine  equal  parts,  or  ich- 
thyol  and  vaseline  equal  parts. 

Siibeutaueous  injection  of  various  antiseptic  solutions  at  the  spreading 
margin,  has  been  recommended.  But  this  gives  the  patient  considerable  pain, 
and  the  results  are  uncertain  and  not  encouraging. 

If  collections  of  pus  form,  they  should  be  incised  and  the  cavities  "washed 
out  "with  hydrogen  peroxide  and  drained. 

PHLEGMONOUS  VULVITIS 

Phlegmonous  vulvitis  is  that  form  in  Avliich  the  bacteria  (usually  the 
staphylococcus  pyogenes  aureus  or  albus")  penetrate  to  the  subcutaneous  con- 
nective tissue  and  cause  inflammation  there.  It  is  kno^^TL  also  as  '^ cellulitis" 
of  vulva  and  as  ''lymphangitis"  of  vulva.  It  lacks  the  superficial  parchment- 
like  induration  of  erysipelas. 

Etiology  and  Pathology.  Anything  that  causes  an  abrasion  about  the 
vulva,  through  which  bacteria  may  reach  the  connective  tissue,  may  lead 
to  phlegmonous  A'ulvitis.  Any  of  the  previously  mentioned  forms  of  vulvitis 
may  be  foUoAved  by  this  form.  Injuries  to  the  vulva  or  furunculosis,  may 
lead  to  the  same.  The  pathologic  changes  are  the  same  as  in  phlegmons 
elsevhere.  There  is  marked  inflammation  of  the  connective  tissue  and  of 
the  lymph  channels.  Eesolution  may  take  place  or  the  process  may  go  on  to 
suppuration.  Occasionally  suppuration  of  the  inguinal  lymphatic  glands  oc- 
curs. 

Symptoms  and  Diagnosis.  The  symptoms  are  those  of  simple  vulvitis 
T\ith  the  addition  of  pain  and  SAvelling,  indicating  deeper  inflammation. 
Sometimes  there  is  considerable  fever,  but  not  ahvays.  The  swelling  may 
be  very  marked,  the  inflammatory  exudate  sometimes  distending  certain 
structures  almost  beyond  recognition. 

It  may  be  comfounded  vith  hematoma  of  vulva.  The  latter  is  distin- 
guished by  the  sudden  onset  folloAving  some  injury  or  slight  surgical  pro- 
cedure, for  example,  the  introduction  of  a  hypodermic  needle  for  the  pur- 
pose of  drawing  off  fluid  from  a  cyst.  The  hematoma  begins  within  a  few 
hours  after  the  injury  and  increases  rapidly  in  size,  with  pain  but  no  fever. 
The  distinctiA-e  signs  of  acute  inflammation  are  absent.  Hematoma  some- 
times occurs  in  pregnancy  AAithout  injury,  being  due  to  subcutaneous  rup- 
ture of  a  varicose  vein. 

When  a  phlegmonous  A'ulvitis  is  confined  to  one  side,  it  may  resemble 
pudendal  hernia  or  pudendal  hydrocele.  In  each  of  these  aft'ections,  acute 
inflammation  is  absent  at  first  and,  also,  there  are  special  characteristics  that 
indicate  the  nature  of  the  SAvelling. 

Treatment.     The  treatment  is  the  same  as  for  cellulitis  or  lymphangitis 


ECZEMA    OF    VULVA  457 

elsewhere.  The  patient  should  stay  hi  bed,  and  hot  compresses,  made  by 
wringmg  absorbent  cotton  out  of  hot  water  or  weak  carbolic  solution,  may 
be  applied  to  relieve  the  pain  and  limit  the  inflammation.  If  there  is  much 
superficial  irritation,  it  may  be  diminished  by  the  measures  given  under 
simple  vulvitis. 

Pelvic  congestion  should,  as  far  as  possible,  be  overcome  by  laxatives 
and  other  measures  as  indicated.  Hot  sitz-baths  sometimes  give  decided  re- 
lief. If  the  inflammation  is  severe  and  spreading  rapidly,  it  may  be  advisable 
to  make  several  incisions  through  the  involved  area,  such  as  are  made  for 
severe  spreading  subcutaneous  inflammation  in  other  localities.  If  an  ab- 
scess forms,  it  must  be  opened  and  drained. 

GANGRENOUS  VULVITIS 

This  is  known  also  as  noma.  It  is  inflammation  of  the  vulva  of  such 
severity  that  the  nutrition  of  the  structures  is  cut  off  and  they  become 
gangrenous.    Extensive  sloughing  may  take  place. 

Gangrenous  vulvitis  occurs  almost  exclusively  in  patients  in  whom  the 
normal  tissue  resistance  has  been  destroyed  by  exhausting  general  or  local 
diseases.  Local  conditions  interfering  with  the  pelvic  circulation,  such  as 
pregnancy  and  pelvic  tumors,  predispose  to  this  affection. 

Its  most  frequent  victims,  however,  are  children  who  are  poorly  nour- 
ished and  poorly  cared  for.  In  such  it  is  often  fatal.  The  exanthemata, 
particularly  when  occurring  in  sickly  children,  may  cause  gangrenous  vul- 
vitis. 

The  treatment  is  the  same  as  for  phlegmonous  vulvitis,  with  the  addi- 
tion of  tonics  and  stimulants,  as  indicated  by  the  patient's  general  condition. 
In  some  cases  it  may  be  advisable  to  excise  the  gangrenous  tissue  and  cauterize 
the  remaining  wound.  The  ulcerated  surfaces  remaining  after  the  sloughs 
separate,  require  the  regular  treatment  for  ulcers  of  the  vulva. 

DIPHTHERITIC  VULVITIS 

Diphtheritic  vulvitis,  like  diphtheritic  vaginitis,  is  simply  diphtheria  with 
anomalous  location  of  the  membrane,  and  requires  the  regular  treatment  for 
diphtheria,  namely,  antitoxin,  stimulants,  nourishment,  and  local  measures 
to  keep  the  infected  surfaces  clean  and  hasten  removal  of  the  membrane.  It 
is  rare,  and  is  due  to  the  same  cause  as  diphtheritic  vaginitis. 

ECZEMA  OF  VULVA 

Vesicular  eczema  of  the  vulva  is  most  frequently  located  on  the  labia 
majora.  The  vesicles  break  and  form  crusts,  and  an  itching,  inflamed  dis- 
charging surface  persists.     Chronic  erythematous  and  squamous  eczema  also 


458  DISEASES    OF    THE    EXTERNAL    GENITALS    AXD    VAGIXA 

may  occur,  in  which  case  the  skin  is  infiltrated  and  may  become  nodular.  The 
eczema  may  be  limited  to  the  Tulva  or  it  may  extend  to  the  adjacent  cutane- 
ous surfaces  or  into  the  vagina. 

Causes  and  Symptoms.  The  predisposing  causes  are  the  same  as  predis- 
pose to  eczema  elsewhere,  namely,  general  nutritive  disturbances  character- 
ized by  gastro-intestinal  disorders  of  rheumatism  or  gout.  The  local  nutritive 
disturbances  accompanying  the  menopause  seem  to  predispose  to  eczema  of 
the  vulva.  The  exciting  cause  is  usually  some  local  irritation,  such  as 
vaginal  discharge,  diabetic  urine  and  other  causes  of  irritation  mentioned 
under  the  etiology  of  simple  A'ulvitis. 

The  symptoms  of  eczema  of  the  vulva  are  practically  the  same  as  of 
eczema  elscAvhere.  i.e.,  burning,  itching,  infiltration  and  induration,  with  some 
thickening  of  the  parts  and  frequently  a  discharge. 

Treatment.  The  indications  for  treatment  are  to  allay  the  local  irri- 
tation and  correct  so  far  as  possible  the  general  nutritive  disturbances,  as  in 
the  treatment  of  eczema  in  other  localities.  Alcoholics,  spices  and  highly 
seasoned  foods  must  be  forbidden.  In  acute  eczema  of  the  vulva,  the  meas- 
ures recommended  under  acute  vulvitis  may  be  employed.  The  lead  and 
opium  wash  gives  much  relief,  or  the  calamine  and  zinc  lotion  may  be  used. 
A  soft  cloth  may  be  wet  in  this  lotion  and  applied  to  the  parts,  being  held 
in  place  by  a  T-bandage.  If  the  irritation  is  marked,  keep  the  cloth  con- 
stantly wet  with  the  lotion.  Another  way  of  applying  the  lotion,  where  the 
irritation  is  not  so  great,  is  to  mop  it  over  the  parts  and  allow  it  to  dry  and 
form  a  protective  coating. 

As  a  cleansing  agent,  hydrogen  peroxide  is  exceedingly  useful  and  may 
be  applied  in  all  stages  of  the  disease,  either  diluted  with  one  or  two  times 
its  volume  of  water,  or  used  full  strength.  Another  excellent  application  in 
acute  eczema  of  this  region  is  the  "black  wash."  This  is  mopped  freely  on 
the  parts  for  several  minutes  and  then  allowed  to  dry.  It  forms  a  protective 
sediment,  over  which  may  be  applied  a  sedative  ointment.  This  application 
may  be  repeated  every  feAv  hours.  During  the  acute  stage,  a  soothing  oint- 
ment such  as  the  zinc  oxide  and  carbolic  ointment  is  useful,  particularly  if 
th©  patient  has  to  be  up  and  about.  This  may  be  applied  each  time  after  the 
application  of  one  of  the  lotions  above  mentioned.  Another  useful  applica- 
tion in  the  acute  form  is  the  oxide  of  zinc  emulsion  in  almond  oil. 

In  the  subacute  and  chronic  cases,  and  these  are  the  most  frequent,  the 
diachylon  ointment  (equal  parts  of  emplastrum  plumbi  and  vaseline  melted 
together)  may  be  used  with  much  benefit.  In  the  more  sluggish  cases,  emplas- 
trum plumbi  undiluted  may  be  used.  Cleanse  the  affected  surface  thorough- 
ly with  green  soap  and  cotton  balls,  dry  it  and  then  apply  diachylon  oint- 
ment spread  on  gauze  or  better  still,  small  strips  of  bandage  muslin.  This 
dressing  should  be  held  firmly  against  the  surface  by  a  T-bandage.  The 
ointment  should  be  kept  applied  continuously  for  several  days,  no  water  being 


INTERTRIGO  459 

used  locally  except  what  is  absolutely  necessary  for  cleanliness.  In  four  or 
five  days  the  cleansing  ^vith  green  soap  may  be  repeated  to  be  followed  by 
the  application  of  the  ointment.  If  the  eczematous  process  is  sluggish  and 
more  stimulation  is  required,  the  diachylon  plaster  (emplastrum  plumbi) 
may  be  used  full  strength,  applied  on  muslin  the  same  as  the  ointment. 

Tar  ointment  is  still  more  stimulating  to  the  skin,  and  sometimes  gives 
better  results  than  the  diachylon  treatment.  It  is  indicated  in  the  dry  scaly 
forms  and  should  be  applied  tentatively  as,  in  some  persons,  it  produces  too 
much  irritation.  Begin  with  a  preparation  containing  a  small  amount  of  tar. 
If  this  produces  no  irritation  and  a  stronger  stimulant  is  needed,  the  quantity 
of  tar  may  be  doubled  and  later  quadrupled.  The  tar  ointment  may  be  ap- 
plied on  strips  of  muslin  or  the  patient  may  rub  it  into  the  surface  with  the 
fingers.  Some  think  the  rubbing  in  of  the  ointment  makes  it  more  effective. 
Tar  ointment  is  not  indicated  when  there  is  deep  infiltration.  It  is  most 
useful  in  the  superficial  chronic  scaly  form. 

When  pruritus  is  marked,  the  application  of  hot  water  for  a  short  time, 
followed  by  the  application  of  an  ointment,  sometimes  gives  much  relief.  The 
ointment  to  be  used  should  be  at  hand  ready  for  application.  Then  a  cloth 
wet  in  very  hot  water  is  applied  to  the  involved  area  and  held  there  for  a 
few  minutes  until  it  begins  to  cool.  The  surface  is  then  dried  with  a  soft 
cloth  or  cotton  and  the  ointment  applied  at  once. 

An  occasional  application  of  silver  nitrate  solution  (4%  to  10%)  is  of 
decided  benefit  in  some  cases. 

In  the  very  chronic  cases,  one  plan  of  treatment  is  to  go  over  the  sur- 
face with  the  sharp  curet  and,  following  the  curetment,  to  rub  into  the 
surface  a  3%  solution  of  salicylic  acid  in  alcohol  and  then  apply  the  diachylon 
ointment  spread  on  muslin.  In  place  of  the  curet  the  affected  area  may  be 
scarified  with  a  knife,  the  scarifications  being  made  deep  enough  to  cause 
considerable  exudate  and  bleeding,  which  may  be  further  promoted  by  the 
application  of  hot  water  for  a  short  time.  Then  the  parts  are  dried  and  the 
salicylic  acid  in  alcohol  applied,  followed  by  the  diachylon  ointment. 

INTERTRIGO 

Intertrigo  is  a  hyperemic  condition  of  the  skin,  with  slight  maceration 
and  consecjuent  irritation.  The  patients  usually  refer  to  it  as  "chafing"  or 
"heat."  It  is  due  to  prolonged  contact  and  friction  of  opposed  surfaces.  The 
normal  skin  secretions  are  retained  between  the  approximated  surfaces  and 
become  decomposed  and  irritating.  It  occurs  most  frequently  in  stout  women 
and  in  infants,  because  in  them  the  skin  surfaces  are  in  contact  more  con- 
stantly and  over  a  wider  area.  It  is  usually  worse  in  hot  weather  because 
the  skin  secretions  are  increased  then,  and  also  because  the  additional  heat 
hastens  decomposition.  Intertrigo  in  this  region  may  be  caused  or,  if  present, 
may  be  made  worse,  by  anything  that  acts  as  an  irritant  to  the  skin,  for 


460  DISEASES    OF    THE    EXTERNAL    GENITALS    AND   VAGINA 

examj)le,  vaginal  discharge,  uncleanliness  and  the  various  etiologic  factors 
mentioned  under  Acute  Vulvitis. 

The  process  may  at^ect  any  surfaces  kept  in  apposition.  It  is  usually 
located  in  the  genito-crural  creases,  but  may  spread  inward  over  the  labia  or 
outward  over  the  thighs  and  upward  on  the  abdominal  wall.  At  first,  inter- 
trigo consists  simj)ly  of  hyperemia  and  slight  irritation  of  the  skin,  but  after 
a  time  there  is  considerable  serous  and  cellular  infiltration,  with  thickening 
and  fissures  and  pigmentation.  Infection  may  take  place  through  some  of 
the  fissures  or  abrasions,  and  the  result  is  an  acute  infiammation  of  the  skin. 

Intertrigo  gives  rise  to  a  great  deal  of  burning  and  itching  and  dis- 
comfort, frequently  to  such  an  extent  that  walking  causes  much  distress. 
When  the  irritation  is  marked,  there  is  a  serous  secretion  from  the  surface, 
which  adds  to  the  patient's  discomfort  and  to  the  local  irritation  by  soiling 
the  adjacent  portions  of  the  clothing.  Clinically  the  dividing  line  between 
intertrigo  and  eczema  is  not  distinct. 

Treatment.  Secure  cleanliness  by  the  frequent  application  of  the  car- 
bolic wash  or  a  strong  solution  of  baking  soda  (tablespoonful  to  a  pint  of 
water).  After  each  washing,  the  parts  should  be  carefully  dried  and  then 
dusted  freely  Avith  some  drying  and  antiseptic  powder,  for  example,  the  zinc 
oxide  and  magnesium  carbonate  powder.  Other  drying  powders  are  men- 
tioned under  Acute  Vulvitis  and  also  under  Pruritus  Vulvae.  After  the  ap- 
plication of  the  powder,  a  piece  of  cotton  or  gauze  should  be  placed  so  as  to 
keep  the  affected  surfaces  from  coming  in  contact. 

The  cleansing  and  dusting  must  be  done  from  three  to  six  times  daily, 
i.e.,  frequently  enough  to  keep  the  surfaces  clean  and  dry.  If  the  patient  can 
rest  in  bed  for  a  few  days,  the  surfaces  may  be  covered  and  kept  separated  by 
pieces  of  gauze  Avet  in  the  calamine  lotion. 

The  treatment  is  much  more  effective  when  the  patient  can  be  kept  quiet 
and  in  bed.  If  she  is  obliged  to  work  during  the  day,  frequent  Avashings,  of 
course,  can  not  be  employed,  and  it  is  then  advisable  to  prescribe  a  sedative 
ointment  such  as  the  zinc  oxide  and  carbolic  ointment  to  be  applied  between 
the  applications  of  the  lotion.  The  surfaces  must  be  kept  separated  by  a 
soft  cloth  or  cotton. 

In  chronic  cases,  some  of  the  stimulating  ointments  mentioned  under 
Eczema  are  beneficial.  Eczema  may  develop  over  an  area  of  intertrigo,  and 
in  that  case  the  treatment  given  under  Eczema  is  required. 

Ravogli  recommends  the  following  measures  for  intertrigo.  When  the 
surface  is  excoriated  and  there  is  considerable  secretion,  keep  the  patient 
in  bed  and  apply  Burow's  solution  in  strength  of  3%,  on  strips  of  lint,  which 
serve  to  keep  the  surfaces  apart.  This  usually  causes  the  intertrigo  to  dis- 
appear after  a  few  applications. 

If  the  patient  must  work,  then  the  bathing  with  the  above  solution  may 
take  place  morning  and  evening,  while  during  the  day  some  sedative  oint- 
ment may  be  applied  to  the  surfaces,  which  should  be  kept  separated  with 


PRURIGO    OF    VULVA  461 

soft  lint.  In  clironie  intertrigo  with  papillary  hypertrophy,  make  two  or 
three  applications  of  Wilkinson's  ointment  which  causes  desquamation  of  the 
old  epidermis,  with  consequent  development  of  new  soft  epidermis.  The 
resorcin  and  salicylic  acid  ointment  has  been  found  effective  in  some  cases. 
To  prevent  relapses,  it  is  well  to  wash  the  creases  in  the  genito-crural 
region  very  frequently  and  keep  them  dusted  with  starch  powder  contain- 
ing 2%  of  boric  acid  or  salicylic  acid,  or  with  some  other  suitable  dusting 
powder. 

HERPES  OF  VULVA 

Herpes  may  occur  on  the  vulva,  where  it  is  known  also  as  "herpes  pro- 
genitalis."  The  vesicles  of  the  herpetic  eruption  are  usually  of  larger  size 
than  those  of  vesicular  eczema.  Furthermore,  they  occur  in  groups  and  do 
not  rupture  easily,  whereas  the  vesicles  of  eczema  rupture  spontaneously,  caus- 
ing a  sticky  discharge.  Herpes  is  seldom  accompanied  by  the  intense  burn- 
ing and  itching  which  characterize  eczema.  Herpes  occurs  especially  in  nerv- 
ous women,  particularly  when  there  is  marked  pelvic  congestion  from  any 
cause.    AVith  some  women  it  occurs  at  nearly  every  menstrual  period. 

The  discomfort  from  uncomplicated  herpes  is  so  slight  that  not  much 
treatment  is  required.  The  parts  should  be  kept  clean  and  dry  and  may  be 
dusted  frequently  with  some  drying  powder,  for  example,  equal  parts  of  zinc 
oxide  and  prepared  chalk.  All  irritation  should  be  avoided.  If  there  is 
troublesome  pruritus  or  burning  or  smarting,  a  sedative  lotion  or  ointment 
may  be  used.  The  erosions  left  by  rupture  of  the  vesicles  should  not  be 
cauterized,  as  it  is  not  necessary  and  may  cause  deep  ulcers. 

PRURIGO  OF  VULVA 

This  is  a  rare  disease  of  the  skin,  beginning  usually  in  early  childhood 
and  reappearing  in  later  life  at  irregular  intervals  and  sometimes  continu- 
ing for  long  periods.  It  is  characterized  by  a  papular  eruption  and  very 
troublesome  itching.  The  papules  are  at  first  of  the  color  of  the  skin  and  are 
more  readily  felt  than  seen,  giving,  on  palpation,  a  rough  "goose-skin" 
sensation.  Later  there  are  various  secondary  changes  (abrasions,  pigmenta- 
tion, desquamation  and  decided  infiltration  and  thickening)  due  to  the  scratch- 
ing excited  by  the  severe  pruritus.  The  pathology  of  the  disease  is  somewhat 
in  doubt,  some  authorities  holding  that  it  is  a  neurosis  and  others  holding 
that  it  is  dilatation  of  the  lymphatics,  causing  irritation  of  the  nerve  filaments 
of  the  skin.  The  disease  is  usually  limited  to  the  extensor  surfaces  of  the 
arms  and  legs,  the  genitals  being  rarely  affected.  When  it  does  affect  the 
genitals,  it  causes  troublesome  and  persistent  pruritus,  helping  to  swell  the 
list  of  eases  of  "pruritus  vulvae." 

In  the  treatment,  the  patient's  general  health  should  be  put  in  the  best 


462  DISEASES    OF    THE    EXTERNAL    GENITALS    AND    VAGINA 

eoiiclition.  The  irritability  of  the  nervous  system  should  be  reduced  by  the 
administration  of  sedatives,  such  as  bromides  or  cannabis  indica.  The  pruritus 
is  diminished  in  some  cases  by  tincture  of  cannabis  indica  by  the  mouth  and 
also  by  pilocarpine  hyiDodermatically.  Locally,  an  ointment  containing  men- 
thol or  both  menthol  and  chloroform,  may  give  much  relief.  Also  the  salicylic 
acid  and  creosote  ointment  has  proved  useful.  If  the  itching  is  severe  and 
persistent  in  spite  of  the  ointments  mentioned,  cocaine  suppositories  may  be 
used  for  temporary  relief.  The  cocaine  suppository  is  to  be  introduced  into 
the  vagina  when  the  itching  is  severe,  and  as  the  suppository  melts  the 
medicine  becomes  distributed  over  the  affected  surfaces.  Other  remedies  for 
the  itching  may  be  found  under  Pruritus,  Vulvae.  Ether  and  alcohol  (1  to  4) 
and  also  chloroform  and  alcohol  (1  to  4)  have  been  recommended  for  the 
purpose  of  dissolving  out  the  tenaeeous  masses  at  the  bottom  of  the  papillae. 

PARASITIC  DISEASES  OF  VULVA 

The  parasitic  diseases,  pediculosis  and  scabies,  occur  here  as  elsewhere 
on  the  body  surfaces.  They  give  rise  to  much  irritation  and,  unless  search 
is  made  for  the  parasites,  the  patient  may  be  treated  ineffectually  for  a  long 
time  for  the  resulting  pruritus  and  irritation. 

Pediculosis  Pubis 

This  is  the  most  common  parasitic  disease  of  the  vulva.  The  pediculus 
pubis  or  "crab  louse"  (Fig.  450)  differs  from  the  pediculi  found  on  other 
parts  of  the  body.     It  i]ihabits  the  pubic  hairy  region  and  may  give  rise  to 


Fig.   456.     The    Pediculus    Pubis,    magnified.       (Stehvagon — Essentials    of    Skin    Diseases.) 

much  irritation.    It  is  conveyed  from  one  person  to  another  by  contact,  usually 
in  sexual  intercourse. 

There  is  itching  and  consequent  scratching,  with  resulting  abrasions 
and  vulvitis.  The  diagnosis  is  made  by  finding  the  parasites  which  are  at- 
tached to  the  hairs  near  the  skin.  At  first  they  may  not  be  noticed,  but  on 
close  inspection  they  are  seen  as  small  brownish  particles  attached  to  the 
hairs  verv  close  to  the  skin. 


SIMPLE   VAGINITIS  463 

The  treatment  is  to  apply  oleate  of  mercury  (10%)  once  daily,  rubbing 
it  well  into  the  hairy  region.  After  the  remedy  has  been  applied  for  four  or 
five  days  it  may  be  washed  off,  and  need  not  be  applied  again  unless  there 
develops  evidence  that  some  of  the  parasites  escaped  destruction.  At  the  end 
of  the  treatment,  a  soap  and  water  bath  and  complete  change  of  underclothing 
must  take  place.  An  elegant  and  effective  preparation  used  in  the  same 
Avay  is  Kaposi's  petroleum  salve.  Some  recommend  to  shave  the  pubis  or  to 
clip  the  hair  there,  but  that  is  usually  not  necessary.  If  there  is  much  local 
irritation  remaining  after  the  parasites  are  killed,  the  measures  given  under 
Simple  Vulvitis  may  be  employed. 

Scabies 

Scabies  may  appear  about  the  external  genitals  as  part  of  an  extensive 
development  of  scabies,  the  infection  usually  appearing  first  on  the  fingers. 
There  are  the  usual  symptoms — severe  itching,  worse  when  the  body  is  warm, 
and  the  abrasions  and  irritation  resulting  from  scratching.  The  diagnosis  is 
made  by  finding  the  burrows  of  the  itch-mite  on  other  portions  of  the  body, 
usually  on  the  fingers. 

The  treatment  consists  of  a  warm  soap-water  bath  followed  by  the  free 
use  of  a  sulphur  ointment.  Immediately  after  the  bath,  the  patient  should 
rub  the  ointment  thoroughly  into  all  the  infected  areas,  and  put  on  clean  un- 
derclothing. The  inunction  should  be  repeated  night  and  morning  for  three 
days,  the  same  underclothing  and  same  bed  linen  being  used  during  the 
course.  On  the  fourth  day  a  warm  soap  bath  should  be  taken  and  clean  under- 
clothing put  on.  If  some  irritation  of  the  skin  remains,  a  mild  ointment,  such 
as  zinc  oxide  ointment  or  carbolized  vaseline,  may  be  used  for  a  few  days. 
If  any  of  the  burrows,  containing  the  ascarus  scabiei,  escape  the  first  unction 
course,  another  similar  course  must  be  carried  out. 

SIMPLE  VAGINITIS 

Simple  vaginitis  is  inflammation  of  the  vagina  due  to  irritation  or  to 
the  ordinary  pus  germs.     It  is  known  also  as  ' 'catarrhal  vaginitis. ' ' 

Etiology.  The  normal  vaginal  secretion  is  destructive  to  the  ordinary 
pus  germs  and  tends  to  protect  the  vaginal  wall,  as  well  as  the  cervix  uteri, 
from  infection.  Anything  that  lowers  the  nutrition  of  the  vaginal  wall  in- 
terferes also  with  the  protective  action  of  the  vaginal  contents  and  hence  pre- 
disposes to  inflammation.  Fasting  diseases  of  every  kind  have  that  effect  to 
some  extent,  but  it  is  especially  noticeable  in  those  conditions  causing  con- 
gestion of  the  vagina,  such  as  pelvic  tumors,  pelvic  inflammatory  affections, 
pregnancy  and  heart  disease.  In  the  presence  of  any  of  the  predisposing 
causes,  and  sometimes  without  them,  vaginitis  may  be  produced  by  the  fol- 
lowing causes: 


464  DISEASES    OF    THE    EXTERNAL    GENITALS    AND    VAGINA 

1.  Use  of  an  infected  syringe  nozzle  or  syringe,  carrying  staphylococci 
or  streptococci  into  the  vagina.  Ordinarily  these  germs  are  killed  by  the 
vaginal  contents,  but  in  cases  in  which  the  nutrition  of  the  vaginal  wall  is 
disturbed  and  the  resistance  consequently  lowered,  these  germs  may  multiply 
rapidly  and  cause  severe  vaginitis. 

2.  An  infective  uterine  discharge,  for  example,  in  acute  septic  endo- 
metritis. 

3.  Decomposition  of  a  chronic  uterine  discharge.  Ordinarily  a  chronic 
discharge  from  the  uterus  passes  out  of  the  vagina,  causing  only  slight  irri- 
tation, but  if  it  is  retained  long  in  the  vagina,  decomposition  takes  place, 
■causing  marked  irritation  and  vaginitis. 

4.  Use  of  very  hot  douches  continued  for  a  long  time,  or  of  strongly  irri- 
tating substances  in  the  vagina,  for  example,  where  a  too  concentrated  douche 
solution  is  used  by  mistake,  or  where  some  irritating  substances  are  intro- 
duced into  the  vagina  for  the  purpose  of  causing  an  abortion. 

5.  Foreign  body  in  the  vagina.  A  pessary  worn  too  long  or  without 
proper  precaution  may  cause  severe  local  vaginitis,  extending  even  to  ulcera- 
tion. In  some  cases  of  this  character  it  has  happened  that  the  ulceration  has 
extended  deeply  into  the  vaginal  wall.  Kelly  illustrates  a  case  in  which 
ulceration  took  place  with  so  much  resulting  cicatricial  contraction  below 
the  pessary,  that  the  vagina  was  occluded  and  a  collection  of  pus  formed 
above  the  point  of  occlusion.  Foreign  bodies  introduced  for  the  purpose  of 
masturbation  are  liable  to  cause  vaginitis. 

6.  In  sexual  intercourse,  germs,  other  than  the  gonococcus,  may  be  car- 
ried into  the  vagina,  and,  if  the  soil  is  favorable,  simple  vaginitis  will  result. 
Again,  slight  traumatisms  in  difficult  coitus  furnish  an  entrance  for  germs, 
with  resulting  vaginitis. 

7.  In  the  exanthemata — measles,  scarlet  fever  and  the  other  eruptive 
diseases — the  eruptive  disturbance  may  extend  to  the  vagina,  causing  much 
irritation  and,  as  a  consequence,  vaginitis. 

Pathology  and  Symptoms.  The  inflammatory  phenomena  are  the  same 
as  in  gonorrheal  vaginitis,  except  not  so  marked.  The  vaginal  walls  present 
active  congestion.  They  are  red  and  hot,  and  manipulations  cause  pain. 
At  first  the  secretion  is  slight,  but  very  soon  it  is  increased  and  becomes 
purulent.  There  is  a  serous  and  cellular  exudate  into  the  vaginal  wall  and 
the  superficial  layers  of  epithelium  are  thrown  off  and  form  part  of  the  discharge. 

In  chronic  cases  the  acute  symptoms  have  disappeared  but  the  cellular 
infiltration  and  epithelial  exfoliation  persist.  The  papillae  may  become 
especially  swollen,  giving  the  sensation  of  a  rough  granular  surface.  The 
longer  the  process  continues,  the  deeper  the  infiltration  extends. 

In  acute  vaginitis  usually  the  first  symptoms  are  dryness,  heat  and 
itching  in  the  vagina  and  about  the  vulva.  Later,  a  discharge  appears  with 
consequent  irritation  about  the  vaginal  orifice  and  the  meatus.     The  vulvar 


SIMPLE    VAGINITIS       -  465 

irritation  and  the  urinary  disturbance  are  nsually  not  nearly  so  marked  as 
in  gonorrhea.  General  disturbances  are  slight.  The  patient  feels  somewhat- 
feverish,  but  decided  rise  of  temperature  is  rare,  and  vhen  present  should 
arouse  suspicion  of  complications. 

Diagnosis.  The  fact  that  the  vagina  is  inflamed  can  be  directly  demon- 
strated in  the  examination,  so  it  remains  only  to  distinguish  simple  vaginitis 
from  the  other  forms  of  vaginal  inflammation. 

Gonorrheal  Vaginitis  is  distinguished  by  the  following : 

a.  Inflammaton  is  rapid  in  development  and  severe. 

b.  Involvement  of  urethra  and  vulvo-vaginal  glands. 

c.  No  other  apparent  cause. 

d.  Gonococci  in  the  discharge. 

e.  History  of  suspicious  coitus  within  a  few  days  before  the  beginning 
of  the  trouble.  In  exceptional  cases  a  simple  vaginitis  may  give  rise  to  a 
simple  urethritis  in  the  husband.  But  simple  vaginitis  never  gives  rise  to  a 
gonorrheal  urethritis,  as  some  husbands  for  obvious  reasons  will  endeavor 
to  make  out. 

Diphtheritic  Vaginitis  is  distingiiished  by: 

a.  Development  of  a  false  membrane  on  the  vaginal  wall. 

b.  Marked  systemic  effects. 

c.  Presence  of  diphtheria  bacilli,  as  demonstrated  by  bacteriologic  ex- 
amination. 

Adhesive  Vaginitis  presents  the  following  characteristics: 

a.  Inflammation  is  only  chronic  or  subacute. 

b.  Occurs  in  patches,  resembling  abraded  areas. 

c.  Walls  of  vagina  adhere,  and  separation  of  the  adhesions  causes  a 
bloody  discharge. 

d.  Patient  is  usually  past  the  menopause. 

Treatment.  In  the  severe  cases  the  same  treatment  is  indicated  as  in 
gonorrheal  vaginitis.  Usually,  however,  the  inflammation  is  comparatively 
mild,  and  an  antiseptic  douche,  such  as  bichloride  1-.5000,  two  or  three  times 
daily  is  all  that  is  required.  The  cause  must  be  sought  and  removed,  for 
example,  if  it  is  due  to  an  irritating  discharge  from  the  uterus,  the  uterine 
lesion  must  receive  appropriate  treatment.  If  the  vaginitis  becomes  chronic, 
the  treatment  described  under  Chronic  Gonorrheal  Vaginitis  should  be 
employed. 

Simple  Vaginitis  in  Children 

In  children  a  troublesome  discharge  sometimes  appears  and  gives  rise  to 
much  vulvar  irritation.  The  trouble  is  frequently  not  severe  enough  to  be 
called  inflammation  of  the  vagina — there  seems  to  be  simply  an  excess  of 
secretion,  causing  a  vaginal  discharge.  But  the  vulvar  irritation,  which  is 
the  most  marked  symptom,  often  necessitates  measures  to  stop  the  excessive 


466 


DISEASES    OF    THE    EXTERNAL    GENITALS    AND    VAGINA 


secretion.  The  treatment  of  this  affection  consists  in  keeping  tlie  external 
genitals  clean  and  dry  by  washing  frequently  with  weak  carbolic  solution, 
then  drying  with  absorbent  cotton  and  then  dusting  A^-ith  a  diying  powder, 
such  as  boric  acid  powder.  Bismuth  subnitrate  and  prepared  chalk,  equal 
parts,  is  also  a  good  dusting  powder.  Keep  the  vulva  covered  with  a  pad 
of  absorbent  cotton. 

The  child  should  be  put  in  first-class  general  health.  Often  the  patient 
presents  lowered  vitality  and  anemia  and  a  general  relaxation  or  want  of 
tone  in  the  tissues — the  so-called  strumous  diathesis.  In  such  a  case,  a  course 
of  tonic  treatment,  restoring  the  patient's  vitality,  will  often  cause  the  dis- 
charge to  cease.  If  the  discharge  persists,  a  mildly  astringent  vaginal  sup- 
pository may  be  introduced  into  the  vagina  once  daily. 

Of  course,  in  severe  vaginitis  in  children,  the  vagina  should  be  irrigated, 
much  the  same  as  in  adults,  but  in  the  mild  disturbance  here  described 
vaginal  irrigation  is  rarely  necessary.  When  it  is  necessary,  the  vagina  may 
be  carefully  washed  out  once  or  twice  daily  with  the  carbolic  or  other  douche 
solution,  using  a  small  soft-rubber  catheter  instead  of  the  ordinary  douche 
nozzle. 

PARASITIC  VAGINITIS 

Parasitic  vaginitis  is  the  term  applied  to  inflammation  of  the  vagina  due 
to  the  same  fungus  which  causes  thrush  in  the  mouth.  It  is  known  also  as 
"mycotic  vaginitis"  and  as  "aphthous  vaginitis." 

The  cause  is  invasion  of  the  vagina  by  parasites  of  the  order  of  oidium 


Fig.   457.     The    Thrush    -Fungus,    under    the    microscope.       (Holt — Diseases    of    Children.) 


albicans,  or,  iDcrhaps  more  correctly,  saccharomyces  albicans.  The  infection 
is  carried  to  the  genitals  usually  by  the  fingers  of  the  patient,  who  has  been 
handling  some  organic  substance  on  Avhich  the  fungus  was  gro■\^^ng.  A 
mother  whose  baby  is  suffering  with  thrush  may  infect  herself.     It  usually 


EMPHYSEMATOUS   VAGINITIS  467 

occurs  in  nursing  women  or  in  pregnant  women  or  in  cases  of  prolapsus  uteri. 
It  is  said  to  occur  sometimes  as  the  result  of  sexual  intercourse  with  a  dia- 
betic husband. 

The  pathologic  changes  are  practically  the  same  as  in  thrush  in  the 
mouth.  There  are  white  patches,  representing  the  growing  fungus,  and 
accompanying  inflammation  of  the  adjacent  tissues.  The  patient  complains 
of  burning,  itching  or  smarting,  but  there  is  not  much  discharge.  In  the 
examination  through  the  speculum,  the  vaginal  wall  presents  the  ordinary 
evidences  of  inflammation  and  in  addition  it  is  studded  with  small  white 
patches  about  the  size  of  the  pinhead.  In  some  cases  small  ulcers  may  form. 
A  scraping  from  one  of  the  white  patches,  examined  with  a  microscope,  will 
show  the  fungus  (Fig.  457). 

Treatment.  Douches  will  give  some  relief,  but  must  be  supplemented 
by  application  through  the  speculum  of  a  more  concentrated  antiseptic,  such 
as  argyrol  25%  or  protargol  10%  or  silver  nitrate  5%  or  bichloride  solution 
(1-500).  After  the  application,  dust  powdered  borax  into  the  vagina  and 
then  introduce  a  tampon  wet  in  50%  boro-glyceride.  Such  treatment,  given 
every  day  or  every  other  day  for  several  weeks  usually  stops  the  disease 
promptly.  After  the  fungus  has  been  destroyed,  mild  antiseptic  douches  are 
required  for  a  time  for  the  accompanying  simple  vaginitis. 

DIPHTHERITIC  VAGINITIS 

This  form  of  vaginitis  is  due  to  infection  of  the  vaginal  wall  by  diph- 
theria bacilli.  It  is  rare.  It  is  liable  to  occur  when  there  is  diphtheria  in  the 
house,  if  there  are  abrasions  of  the  vagina,  particularly  after  labor. 

Diphtheritic  vaginitis  is  characterized  by  the  development  of  a  false  mem- 
brane over  the  abraded  areas  and  by  the  marked  systemic  effects  of  diph- 
theria, in  addition  to  the  usual  signs  of  vaginitis.  Streptococci  sometimes 
cause  a  membrane.  The  differential  diagnosis  is  made  by  the  surrounding 
inflammation  and  the  systemic  disturbances  in  the  two  diseases,  and  especially 
by  a  bacteriologic  examination  when  that  is  available. 

The  treatment  should  include  the  measures  recommended  for  simple 
vaginitis,  and,  in  addition,  antitoxin  and  other  remedies  indicated  in  diph- 
theria. 

EMPHYSEMATOUS  VAGINITIS 

In  emphysematous  vaginitis,  small  collections  of  gas  appear  under  the 
epithelium  or  in  the  meshes  of  the  connective  tissues.  It  is  a  rare  form  of 
vaginal  inflammation  and  occurs  almost  exclusively  in  pregnant  women. 
Its  seat  is  the  upper  part  of  the  vagina  and  the  vaginal  portion  of  the  cervix. 
The  little  air  vesicles  are  close  set  and  vary  from  the  size  of  a  pinhead  to 
several  times  as  large.     They  are  frequently  surrounded  by  an  area  of  hyper- 


468  DISEASES    OF    THE    EXTERNAL    GEXITALS    AXD    VAGIX^A 

emia,  but  the  inflamiiiatory  reaction  is  slight.  AVhen  punctured  the  air 
escapes  and  the  vesicle  collapses.  There  is  rarely  any  secretion  from  them. 
The  gas  contained  in  them  is,  in  part  at  least,  trimethylamine.  The  vesicles 
show  little  tendency  to  reform  after  puncture.  The  affection  is  due  to  a 
mild  gas-producing  bacillus.  But  it  apparently  bears  no  relation  to  infection 
with  the  gas-forming  bacillus  known  as  the  bacillus  aerogenes  capsulatus, 
for  this  deadly  germ  gives  rise  to  a  severe  and  rapidly  spreading  phleg- 
monous inflammation. 

As  to  the  treatment  of  emphysematous  vaginitis,  nothing  more  is  usually 
required  than  puncturing  the  air  vesicles  and  washing  of  the  vicinity  with 
an  antiseptic  solution.  If  there  is  an  irritating  discharge,  mild  antiseptic 
douches  may  be  given.  If  the  patient  is  pregnant,  great  care  must  be  exer- 
cised not  to  cause  much  irritation,  as  an  abortion  might  result. 

ADHESIVE  VAGINITIS 

Adhesive  vaginitis  is  the  term  given  to  that  form  of  vaginal  inflamma- 
tion in  which  there  is  a  tendency  of  the  opposed  surfaces  to  become  adherent. 
It  occurs  almost  exclusively  in  women  past  the  menopause,  hence  the  name 
''senile  vaginitis"  by  which  it  is  often  designated.  Occasionally  it  occurs  in 
children.  The  predisposing  cause  in  most  cases  is  the  disturbance  of  nutri- 
tion due  to  old  age.  The  exciting  cause  is  probably  a  slight  uterine  dis- 
charge, which  macerates  the  vaginal  epithelium  and  produces  considerable 
irritation.  A  certain  amount  of  senile  vaginitis  is  very  frequent  and  often 
produces  no  symptoms.  In  fact  it  is  probable  that  only  a  small  proportion 
of  women  over  sixty  are  entirely  free  from  some  disturbance  of  this  kind, 
with  slight  adhesions  here  and  there. 

Over  irregular  patches  the  superficial  layers  of  epithelium  are  throv^l 
off  (Fig.  458),  forming  erosions  from  which  there  is  a  scanty  secretion.  The 
eroded  areas  are  tender  and  usually  bleed  on  manipulation. 

When  such  areas  develop  on  opposed  surfaces  of  the  vaginal  walls 
adhesions  take  place  between  them.  For  a  long  time  the  adhesion  is  weak 
and  the  surfaces  may  be  easily  separated.  If  the  process  of  adhesion  is 
allowed  to  go  on  undisturbed,  the  adhesions  become  organized  and  firni,  and 
in  the  course  of  time  may  become  so  extensive  and  strong  that  the  vagina  is 
practically  obliterated.  Adhesive  vaginitis  is  accompanied  by  a  slight 
"gluey"  discharge,  small  in  amount  but  irritating. 

The  symptoms  are,  vaginal  discharge,  sometimes  bloody,  with  some  pain 
in  the  pelvis  and  vaginal  burning  and  discomfort.  There  may  be  some  burn- 
ing or  smarting  on  urination,  from  irritation  of  the  vulva  by  the  discharge. 

On  digital  examination,  the  vaginal  walls  are  felt  adherent  in  places, 
especially  at  the  upper  portion  of  the  vagina,  and  the  separation  of  the  walls 
causes   some   pain   and   bleeding.      Examination    of   the    vagina    through   the 


ADHESIVE    VAGINITIS 


469 


speculum  shows  hemorrhagic  areas  of  denudation  and  inflammation,  principally 
in  the  upper  i)art  of  the  vagina. 

Diagnosis.  The  evidence  of  subacute  vaginitis  with  marked  tendency 
to  adhesion  of  the  walls  in  spots,  establishes  the  diagnosis  of  adhesive  vagin- 
itis. Vaginitis  occurring  after  the  menopause  is  usually  of  this  form.  Be 
careful  to  distinguish  gonorrheal  vaginitis  from  the  ordinary  adhesive  vagin- 
itis. Serious  disease  of  the  uterus  causing  discharge,  particularly  cancer, 
must  be  excluded. 

Treatment.  If  the  trouble  is  slight  and  causing  no  symptoms,  it  needs 
no  treatment.  The  adhesions  in  themselves  cause  no  trouble  and  consequently 
need  no  treatment. 

When  the  disturbance  gives  rise  to  an  irritating  discharge  or  to  bleeding 
or  to  pain,  then  the  following  treatment  is  indicated : 

1.  Put  the  patient  in  the  best  possible  general  health. 

2.  Keep  the  vagina  free  from  the  irritating  discharge  by  the  use  of  a 
mild  antiseptic  douche,  such  as  the  carbolic  douche,  two  or  three  times  daily. 
If  the  parts  are  atonic  and  show  a  marked  tendency  to  bleed,  an  astringent 
douche,  such  as  the  alum  and  zinc  sulphate  douche  may  be  used. 

used. 


Fig.  458.  Indicating  the  condition  in  an  area  of  Adhesive  Vaginitis.  The  epithelium  is  thrown 
off.  The  granulating  surface  left  may  unite  with  a  similar  area  on  the  opposite  wall,  causing  adhesions 
as  described.      (Breisky — Diseases  of  Vagina.) 


3.  Every  second  or  third  or  fourth  day,  depending  on  the  severity  of 
the  vaginitis,  make  a  vaginal  application  of  some  astringent  and  antiseptic, 
for  example,  argyrol  25%  or  protargol  5%  to  10%,  acetum  pj^roligjiiosum, 
proving  particularly  useful  for  this  purpose.  This  should  be  applied 
thoroughly  to  all  parts  of  the  vaginal  wall  involved  in  the  inflammatory 
process.  If  the  hemorrhagic  tendency  is  marked,  an  application  more  strongly 
astringent,  such  as  copper  sulphate  solution  (10%)  may  be  used. 

After  the  application,  some  measure  should  be  employed  to  keep  the 
vaginal  walls  separated,  at  least  for  a  time.  For  this  purpose  we  may  use 
cotton  tampons  or  gauze  strips  soaked  in  carbolized  glycerine  (2%)  or 
covered  with  carbolized  zinc  oxide  ointment  (2%  to  5%),  or  the  ointment 
may  be  spread  on  the  vaginal  Avails  and  then  the  tampons  introduced.  Car- 
bolized olive  oil  (2%  to  5%)  makes  a  soothing  application  to  the  vaginal 
walls   and   prevents   adhesion   of   the    opposed   surfaces.     In   very   sensitive 


470  DISEASES    OF    THE   EXTERNAL    GENITALS    AND    VAGINA 

cases,  either  almond  oil  or  ungentum  aquae  rosae  may  give  more  relief  than  the 
other  remedies  mentioned.  For  use  at  home,  between  the  office  applications, 
astringent  vaginal  suppositories  are  sometimes  beneficial. 

4.  The  exciting  cause  of  the  trouble  must  be  sought  and,  if  possible, 
removed.  Frequently  it  will  be  found  to  be  an  irritating  discharge  due  to 
senile   endometritis,   which   must,    of   course,   receive   appropriate   treatment. 

SIMPLE  ULCERS 

OF  Vulva  and  Vagina 

Ulcers  or  ulceration  of  the  vulva  or  vagina  may  indicate  the  following  con- 
ditions: 

1.  Simple  irritation  or  pus  infection.  Any  of  the  numerous  irritants 
that  cause  vulvitis  may  cause  one  or  more  ulcers,  as  may  also  infection  at 
any  point  with  ordinary  pus  germs. 

2.  Chancroidal  infection. 

3.  Syphilis. 

4.  Tuberculosis. 

■    5.  Malignant  disease. 
6.  Ulcus  rodens  vulvae. 
Those  coming  in  the  first  class  constitute  the  simple  ulcers. 

Pathology  and  Symptoms.  The  simple  ulcers  are  the  ones  considered 
here — the  other  varieties  will  be  taken  up  later.  The  essential  feature  of  an 
ulcer  is  that  the  epithelial  coat  is  lost  down  to  the  connective  tissue,  the  base 
being  covered  with  granulation  tissue  or  a  slough.  The  infecting  germs  lie 
in  the  tissues  close  to  the  surface  of  the  ulcer,  and  outside  them  is  a  limiting 
zone  of  round-cell  infiltration.  There  is  more  or  less  discharge  from  the 
surface  of  the  ulcer,  and  it  usually  bleeds  on  slight  manipulation.  These 
characteristics  pertain  to  all  varieties  of  ulcer.  There  is  some  pain  and 
tenderness  about  the  ulcer,  and  the  discharge  may  cause  considerable 
irritation.  If  the  ulcer  is  situated  so  that  the  urine  flows  over  it,  the  patient 
may  experience  smarting  and  burning  on  urination. 

Diagnosis.  The  diagnosis  of  ulcer  presents  no  difficulties,  as  it  is  estab- 
lished by  finding  an  area  devoid  of  epithelial  covering  presenting  a  granulat- 
ing surface.  An  eroded  area  on  the  vulva  or  in  the  A^agina,  which  is  sensitive 
and  bleeds  easily,  may  be  mistaken  for  an  ulcer,  but  close  inspection  will  show 
that  the  surface  is  still  covered  with  a  thin  layer  of  epithelium. 

The  diagnosis  of  the  variety  of  ulcer  present  is  very  important  and 
sometimes  difficult.  From  simple  ulcer  there  must  be  distinguished  the 
chancroidal,  the  syphilitic,  the  tubercular  and  the  malignant  ulcer. 

The  chancroidal  ulcer  presents  a  ragged  or  irregular  base  with  punched- 


SIMPIiE    ULCERS    OF    VULVA    AND    VAGINA  471 

out  or  undermined  edges,  and  a  tendency  to  spread  and  also  to  infect 
surfaces  with  which  the  secretion  comes  in  contact  (Fig.  211).  The  chan- 
croidal ulcer  appears  within  a  few  days  after  suspicious  coitus.  It  is  tender 
and  sometimes  quite  painful,  and  is  liable  to  be  accompanied  with  painful 
inguinal  adenitis,  in  which  the  glands  become  matted  together  and  later 
suppurate. 

There  is  no  marked  induration  underlying  the  sore — it  is  a  "soft  sore." 
On  account  of  the  infective  character  of  the  secretion,  other  ulcers  appear, 
and  frequently  the  ulcers  of  the  vulva  are  complicated  by  ulcers  about  the 
anus.  It  often  happens  that  these  lesions  about  the  anus  give  rise  to  more 
troublesome  symptoms  than  the  vulvar  ulcers  and  are  really  what  causes 
the  patient  to  seek  relief. 

Syphilitic  Ulcers  are  of  two  kinds,  the  primary  lesion,  called  also 
"chancre"  or  "hard  sore,"  and  the  deep  tertiary  ulcers.  The  character- 
istic primary  sore  of  syphilis  becomes  apparent  two  to  four  weeks  after 
suspicious  coitus.  It  is  small  and  not  particularly  painful,  but  presents  an 
underlying  area  of  induration  which  feels  to  the  examining  fingers  as  though 
a  small  piece  of  stiff  paper  were  lying  beneath  the  ulcer.  The  inguinal 
adenitis,  which  appears  after  a  short  time,  is  practically  painless  and  there 
is  no  tendency  to  suppuration  nor  to  matting  together  of  the  glands.  How- 
ever, the  primary  sore  is  seldom  so  distinctly  characteristic  that  it  is  justi- 
fiable to  begin  constitutional  treatment  before  secondary  manifestations 
confirm  the  diagnosis.  The  superficial  secondary  lesions,  which  about  the 
vulva  appear  as  flat  condylomata,  are  not  really  ulcers  but  simply  erosions. 
The  ulcers  appearing  in  the  later  stages  of  syphilis  are  usually  ragged, 
irregular,  indolent  and  persistent,  and  there  are  other  evidences  of  syphilis. 
In  a  doubtful  case,  a  course  of  potassium  iodide  may  assist  in  clearing  up 
the  diagnosis. 

By  a  bacteriologic  examination  of  a  piece  of  tissue  excised  from  the 
lesion,  a  positive  diagnosis  may  be  made  at  once,  in  the  primary  or  secondary 
or  tertiary  stage  of  the  disease  (see  under  Syphilis,  page  479). 

In  tubercular  ulcer  there  may  be  other  organs  presenting  tuberculosis. 
Also  the  nature  of  the  ulcer  is  indicated  by  its  appearance,  by  finding  tubercle 
bacilli  in  the  discharge  or  scrapings  and,  if  still  doubtful,  by  the  examina- 
tion of  sections  of  tissue  from  the  margin  of  the  sore. 

In  malignant  ulcer,  that  is,  an  ulcer  due  to  the  breaking  down  of  tissue 
infiltrated  with  carcinoma  or  sarcoma  cells,  there  is  a  surrounding  area  of 
induration,  representing  that  portion  of  the  malignant  infiltration  which  has 
not  yet  broken  down.  A  malignant  ulcer  is  chronic  and  bleeds  easily,  and 
the  tendency  to  bleed  is  not  checked,  but  rather  increased,  by  the  applica- 
tion of  10%  copper  sulphate  solution.  In  the  case  of  a  chronic  ulcer  of 
doubtful  character,  a  piece  of  the  margin  of  the  ulcer  should  be  excised  for 
microscopic  examination.     Carcinoma  in  this  situation  causes  death  in  about 


472  DISEASES    OF    THE    EXTERNAL    GENITALS    AXD    YAGIXA 

t\YO  years.     To  remove  tlie  growth  completely,  the  operation  must  be  per- 
formed in  a  very  early  stage,  hence  the  importance  of  an  early  diagnosis. 

Treatment.  The  first  efforts  in  the  treatment  of  any  ulcer  of  the  ex- 
ternal genitals  should  be  directed  toward  securing  cleanliness  and  allaying 
irritation,  by  the  measures  recommended  under  Acute  Vulvitis.  In  simple 
ulcer,  after  cleansing  with  carbolic  or  bichloride  solution  and  drying  with 
absorbent  cotton,  the  patient  may  apply  an  antiseptic  ointment,  such  as 
carbolized  vaseline  (1%)  or  the  chloretone  ointment.  This  cleansing,  fol- 
lowed by  the  application  of  the  ointment,  may  be  carried  out  two  or  three 
times  daily  by  the  patient  at  home,  or  more  frequently  if  there  is  much 
discharge.  A  very  efficient  cleansing  application  for  the  patient's  use  is 
hydrogen  peroxide.  Every  second  or  third  day  apply  some  astringent,  such 
as  protargol  (10%)  or  silver  nitrate  solution  (10%)  or  copper  sulphate 
solution  (10%),  to  all  portions  of  the  surface  of  the  ulcer,  and  after  that 
an  astringent  antiseptic  powder.  The  genitals  should  be  kept  covered  A^dth 
a  piece  of  absorbent  cotton  held  in  place  by  a  T-bandage.  If  there  is  an 
accompanying  vaginal  discharge,  the  patient  should  take  an  antiseptic 
douche  one  to  three  times  daily.  If  these  cleansing  and  antiseptic  measures 
do  not  cause  the  ulcer  to  heal  promptly,  it  is  probably  not  a  simple  ulcer  but 
■belongs  to  one  of  the  special  varieties. 

CHANCROID 

OF  Vulva  axd  Vagix^a 

Chancroid  is  an  infectious  ulcer,  entirely  local  in  its  effects  and  due  to 
inoculation  Avith  secretion  from  another  chancroid.  It  is  known  also  as 
''soft  chancre"  and  as  "soft  sore."  It  constitutes  one  of  the  three  so-called 
"venereal  diseases"   (gonorrhea,  chancroid,  syphilis). 

It  is  due  to  a  specific  infectious  agent  which  causes  chancroid  and 
nothing  else.  It  is  invariably  due  to  contact  with  virus  from  another 
chancroid,  and  sexual  intercourse  is  nearly  always  responsible  for  this  con- 
tact. 

The  infectious  principle  of  chancroid  is  much  more  exclusively  conveyed 
by  sexual  intercourse  than  syphilis.  Conversely,  chancroidal  virus  is  much 
less  liable  than  syphilitic  virus  to  be  conveyed  in  an  active  state  simply  by 
contaminated  articles.  However,  such  method  of  conveyance  is  probably 
possible  and  must  be  guarded  against.  The  chancroidal  virus  does  not  pene- 
trate healthy  epithelium  but  makes  its  entrance  through  a  crack  or  abrasion. 

The  infectious  agent  is  a  short  bacillus,  discovered  by  Ducrey  and  hence 
designated  as  the  Ducrey  bacillus.  It  occurs  in  the  discharge,  but  can  not  be 
satisfactorily  identified  there  because  of  contaminating  material.  For  diag- 
nostic examination  a  tissue  specimen  should  be  secured. 

In  the  case  of  enlarged  glands,  the  serum  secured  by  puncture  with  a 
large  hollow  needle  is  usually  satisfactory  for  diagnostic  examination. 


CHANCROID  473 


Pathology 


Within  twenty-four  to  forty-eight  hours  after  infection,  there  appears 
a  small  postule  on  an  inflammatory  base.  This  point  of  infection  may  be 
situated  at  any  i^art  of  the  external  genitals  or  in  the  vagina.  This  begin- 
ning lesion  may  not  be  noticed  by  the  patient,  so  that  according  to  her  state- 
ment the  lesion  may  not  have  appeared  for  several  days  or  a  week  after 
coitus.  In  a  short  time  the  epithelial  covering  over  the  infected  spot  is  lost 
and  a  small  ulcer  is  thus  formed.  This  ulcer  has  sharp,  punched-out  margins, 
a  rough  and  sometimes  necrotic  base,  is  surrounded  by  a  red  inflammation 
zone  and  is  accompanied  by  more  or  less  inflammatory  edema.  In  cases  of 
long  standing  or  of  much  inflammation,  there  may  be  considerable  round- 
cell  infiltration  and  induration  around  the  ulcer  and  under  it,  but  there  is 
rarely  if  ever  the  marked  parchment-like  or  cartilage-like  induration  that 
develops  under  the  primary  lesion  of  syphilis. 

Usually  the  ulcer  gradually  enlarges  and  deepens,  the  destruction  as  a 
rule  being  more  rapid  and  extensive  in  the  vagina  than  on  the  external  surface. 
During  this  stage  the  base  of  the  ulcer  usually  shows  sloughing  tissue  or 
false  membrane,  and  the  surrounding  inflammatory  zone  is  marked.  Alco- 
holic drinks,  friction  from  exercise  and  also  uncleanliness,  increase  and  pro- 
long the  destructive  action.  Ordinarily  after  several  days,  the  time  depend- 
ing somewhat  on  the  patient's  habits  and  general  health,  the  ulcer  shows  a 
tendency  to  heal.  Under  treatment,  the  base  clears  otf  and  shows  apparently 
healthy  granulation  tissue,  the  surrounding  inflammatory  zone  grows  less  and 
the  secretion  becomes  more  like  ordinary  pus.  Gradually  the  granulating 
surface  is  replaced  by  a  thin  layer  of  scar,  which  begins  at  the  margin  and 
progresses  towards  the  center.  The  usual  duration  of  a  chancroid  is  two 
to  three  weeks.  A  relapse  may  occur  at  any  stage  of  the  healing  process 
and  even  when  apparently  healed,  the  lesions  are  for  some  time  infectious. 

Such  is  the  regular  course  of  a  chancroidal  ulcer,  but  several  other  con- 
ditions may  develop,  as  follows: 

a.  In  chronic  alcoholics  and  other  subjects  of  diminished  resistance,  the 
ulcer  may  present  ragged  and  undermined  edges  and  become  very  destruc- 
tive and  rapid  in  its  advancement,  constituting  what  is  knoAvn  as  a  phage- 
denic chancroid. 

b.  Any  surface  which  lies  against  a  chancroid  is  liable  to  develop  a 
secondary  chancroid  at  the  point  of  contact,  after  sufficient  time  for  the 
irritating  discharge  from  the  primary  chancroid  to  cause  an  erosion  and  thus 
open  an  avenue  for  infection.  Again,  if  pus  from  a  chancroid  comes  in  con- 
tact with  a  scratch  or  abrasion  in  the  vicinity,  it  causes  another  chancroid. 

This  is  called  autoinoculation  and  it  is  one  of  the  marked  character- 
istics of  chancroidal  lesions  in  contradistinction  to  the  syphilitic  chancre.  It 
is  also  one  of  the  strong  proofs  of  the  purely  local  character  of  chancroid. 
On  account  of  this  property,  chancroids  are  usually  multiple.     There  may  be 


474  DISEASES    OF    THE    EXTERXAL    GEX'ITALS    AX'D    VAGIX^'A 

two  or  three  or  there  may  be  many  (Fig.  201).  Frequently  the  secretion 
runs  do^^ii  over  the  anus,  where  it  comes  in  contact  with  abrasions  and  causes 
chancroidal  ulcers  that  are  more  painful  than  the  vulvar  lesions.  Sometimes 
the  infective  secretion  penetrates  the  hair  follicles  or  sebaceous  glands  of 
the  vulva,  forming  small  round  sores  called  follicular  ulcers. 

c.  Xot  infrequently  the  A'irus  is  carried  by  the  lymphatics  to  the  inguinal 
glands  and  there  causes  chancroidal  bubo  vhich  usually  suppurates  and  gives 
rise  to  a  discharge,  which  is  as  infective  as  that  from  the  original  ulcer.  Of 
course,  ordinary  pus  germs  accompany  chancroidal  inflammation,  and  the 
ordinary  pus  germs  may  cause  a  simple  bubo,  not  containing  any  chancroidal 
virus.  Such  a  bubo  would  not  of  course  be  a  chancroidal  bubo,  but  would  be 
a  simple  bubo  accompanying  a  chancroidal  ulcer.  It  is  not  settled  just  what 
proportion  of  buboes  are  of  this  class. 

d.  It  sometimes  happens  that  syphilitic  infection  takes  place  at  the  same 
time  as  the  chancroidal  infection  or  just  before  it  or  after  it.  This  consti- 
tutes a  mixed  infection  which  not  infrequently  causes  a  mistake  in  diagnosis 
and  much  chagrin  on  the  part  of  the  physician,  who  sees  unmistakable  evi- 
dences of  syphilis  develop  from  a  sore  which  he  had  pronounced  simply  a 
chancroid.  For  the  first  two  or  three  weeks  there  may  be  nothing  to  indicate 
that  syphilitic  infection  has  taken  place,  but  after  that  time  the  ulcer,  in- 
stead of  cicatrizing  as  a  chancroid  should  do,  develops  the  induration  and 
other  characteristics  of  a  syphilitic  sore.  This  mixed  infection  occurs  rather 
frequently  and  its  possibility  in  any  particular  case  must  be  kept  in  mind, 
that  due  caution  may  be  exercised  in  giving  the  diagnosis  and  prognosis. 

Symptoms 

There  may  be  few  or  no  symptoms,  except  when  the  ulcer  is  touched  or 
rubbed  by  the  clothing.  In  some  cases  the  patient  complains  only  of  a  dis- 
charge and  smarting  on  urination.  She  may  be  unaware  that  any  sore  is 
present  on  the  genitals.  On  the  other  hand,  the  patient  may  complain  of 
much  itching  and  of  other  symptoms  of  acute  vulvitis  due  to  the  irritating 
discharge.  If  the  ulcer  is  so  situated  that  the  urine  flows  over  it,  there  is 
usually  considerable  smarting  and  pain  on  urination.  AVhen  situated  in  the 
vagina,  the  ulcer  gives  rise  to  an  irritating  discharge,  frequently  blood- 
streaked,  and  also  to  other  symptoms  of  vaginitis. 

In  multiple  chancroids,  the  discomfort  is  accordingly  increased,  and  in 
phagedenic  chancroid  the  general  health  may  be  seriously  impaired.  In 
chancroids  about  the  anus,  there  is  much  pain,  particularly  on  defecation, 
and  occasionally  the  excruciating  pain  of  anal  fissure  appears. 

If  infection  of  the  lymphatic  glands  takes  place,  the  patient  complains 
of  pain  in  the  affected  groin,  increased  by  walking,  and  of  a  tender  lump 
in  the   sroin.     The  conditions  found  on  examination  of  a   chancroidal  ulcer 


TREATMENT    OF    CHANCROID  475 

have  been  described  under  pathology.     In  the  case  of  mixed  infection,  symp- 
toms of  secondary  syphilis  develop  after  sufficient  time  has  elapsed. 

Diagnosis 

The  diagnosis  of  chancroid  is  based  on  the  following  jpoints : 

1.  Development  within  a  few  days  or  a  week  after  suspicious  coitus. 

2.  Location  and  mode  of  development  and  appearance  of  the  lesion. 

3.  Two  or  more  lesions,  indicating  autoinoculation. 

4.  Absence  of  parchment-like,  or  cartilage-like,  induration  under  the 
ulcer. 

5.  Presence  of  a  painful  bubo  tending  to  suppuration. 

6.  In  a  doubtful  case,  a  piece  of  tissue  may  be  excised  from  the  involved 
area,  and  submitted  to  a  bacteriologic  examination,  to  establish  the  presence 
or  absence  of  the  Ducrey  bacillus. 

A  Simple  Ulcer  may  be  due  to  an  abrasion  in  the  first  intercourse  after 
marriage,  or  to  infection  of  a  denuded  point  with  ordinary  pus  germs.  A 
simple  ulcer  is  not  so  exclusively  associated  with  coitus,  does  not  give  rise 
to  so  much  inflammatory  reaction  nor  exhibit  such  an  angry  appearance, 
does  not  show  such  a  tendency  to  spread  and  destroy  tissue.  If  kept  clean 
for  a  few  days,  it  shows  healthy  granulations  and  healing  edges,  is  more 
liable  to  be  single  (as  autoinoculation  is  not  so  frequent  and  marked)  and 
involvement    of   the   lymphatic    glands   with   suppuration    is   rare. 

In  Herpes,  the  abrasion  is  preceded  by  a  vesicular  eruption  and  there 
are  usually  several  lesions  close  together  or  joined.  The  lesion  is  very  super- 
ficial, the  red  surface  being  still  covered  with  a  thin  layer  of  epithelium. 
The  margin  is  small  and  regular  and  there  is  but  little  inflammatory  reaction. 

It  must  not  be  forgotten,  however,  that  an  herpetic  lesion  may  afford 
entrance  to  ordinary  pus  germs  or  to  chancroidal  virus  or  to  syphilitic  infec- 
tion, in  which  case  characteristic  signs  will  develop  in  due  time.  For  the 
distinguishing  characteristic  of  syphilitic  lesions  and  tubercular  ulcer  and 
malignant  ulcer,  see  the  succeeding  pages. 

Treatment 

The  treatment  for  chancroid  is  thorough  cauterization,  to  destroy  the 
chancroidal  virus.  The  earlier  this  is  done  the  fewer  ulcers  there  will  be  and 
the  less  chance  of  suppurating  bubo. 

Carbolic  acid  (95%)  is  the  preferable  cauterant  in  the  cases  where  the 
ulcer  is  comparatively  superficial.    No  general  anesthetic  is  necessary. 

The  ulcer  is  cleansed  and  then  covered  with  a  pledget  of  cotton  soaked 
in  20%  cocaine  solution,  which  is  left  in  place  five  minutes.  Then  remove 
the  cotton  and  cleanse  the  surface  of  the  ulcer  again.  Then  cauterize  every 
portion  of  the  ulcer  with  the  carbolic  acid.     For  applying  this,  a  toothpick 


476  '      DISEASES    OF    THE    EXTERNAL    GENITALS    AND    VAGINA 

with  a  few  shreds  of  cotton  wound  firmly  on  the  end  of  it,  is  very  convenient,. 
or  a  cotton-wrapped  applicator  may  be  used.  If  any  of  the  carbolic  acid 
should  touch  the  skin,  an  immediate  application  of  alcohol  will  stop  destruc- 
tive action. 

Rub  the  carbolic  acid  into  every  crevice  and  irregularity  of  the  ulcer, 
removing  any  soft  granulations  and  working  the  cauterant  into  the  depth 
of  the  affected  area.  When  the  surface  has  been  thoroughly  cauterized  then 
apply  alcohol  to  stop  further  action.  Then  cleanse  the  ulcer  and  apply 
some  soothing  ointment.     Vaseline  or  carbolized  vaseline  does  very  well. 

The  patient  should  keep  rather  quiet  (lie  down  most  of  the  time  if  she 
can)  for  a  tew  days.  She  should  cleanse  the  parts  frequently  with  the  car- 
bolic wash  or  other  antiseptic  wash  and  dry  with  cotton  and  apply  the  vase- 
line or  other  ointment.  There  is  some  reaction,  but  that  subsides  after  a  few 
days,  and  the  ulcer  begins  to  show  healthy  granulations  and  rapid  healing. 
After  that  the  treatment  is  the  same  as  for  a  simple  ulcer. 

In  cauterizing  the  ulcer  it  is  important  that  every  particle  of  the  infected 
surface  should  be  thoroughly  cauterized,  for  if  active  virus  is  left  at  any 
point,  it  will  reinfect  the  enlarged  ulcer  after  the  sloughs  from  cauteriza- 
tion separate. 

The  advantage  of  carbolic  acid  over  nitric  acid  or  the  thermo-cautery 
is  that  it  is  less  painful.  It  has  an  anesthetic  effect  that  lasts  for  some  time 
after  the  cocaine  anesthesia  has  disappeared.  If  the  ulcer  becomes  very 
painful  from  the  reaction  following  cauterization,  hot  applications  may  give 
much  relief.  These  are  made  by  wringing  a  large  piece  of  absorbent  cotton 
out  of  hot  water  or  hot  antiseptic  solution.  The  moist  cotton,  while  still 
steaming,  is  applied  to  the  genitals  and  covered  with  a  piece  of  oiled  silk. 
These  hot  applications  may  be  used  frequently  if  required  to  relievci  pain. 
If  the  sore  is  in  the  vagina,  hot  antiseptic  douches  should  be  used. 

At  the  office  treatments,  later,  the  ulcer  is  cleansed  with  hydrogen  perox- 
ide, dried  Avith  absorbent  cotton  and  then  dusted  freely  with  some  antiseptic 
powder.  Iodoform  is  efficient,  but  its  odor  prevents  its  use.  There  are  a 
number  of  good  powders  without  the  odor.  Among  the  best  are  xeroform 
and  aristol. 

The  ulcer  should  be  protected  from  irritation  from  the  clothing  by  a  pad 
of  absorbent  cotton  over  the  genitals.  The  office  treatment  is  repeated  every 
second  or  third  day  until  the  ulcer  is  healed.  For  home  treatment,  the  pa- 
tient may  wash  the  genitals  three  or  four  times  daily  with  a  weak  carbolic 
solution  or  some  other  mild  antiseptic. 

If  pain  or  restlessness  is  marked,  a  sedative  may  be  given  as  required  to 
produce  rest.  If  the  patient's  general  health  is  poor,  she  should"  of  course  be 
given  tonics.  The  diet  should  be  liberal  and  nourishing.  Alcoholics  are  to 
be  avoided  in  most  cases.     Constipation  must  be  overcome. 

There  is  no    specific    internal    treatment    for    chancroid.     The    following 


treat:mext  of  chancroid  477 

remedies  have  been  thought  by  different  observers  to  help  in  controlling  the 
ulceration,  and  it  is  well  to  use  one  of  them  in  severe  cases : 

Calcium  Sulphite,  1-12  to  1-8  gr.  every  four  hours. 
Hydrarg-biehloride,  1-50  to  1-30  gr.  three  times  daily. 
Potassio-tartrate  of  Iron,  3  to  5  gr.  three  times  daily. 

In  phagedenic  chancroid  cauterization  is  the  most  effective  treatment. 
The  cauterization  must  be  thorough,  extending  into  every  irregularity  of  every 
chancroidal  lesion  present,  for  if  active  virus  is  left  at  any  point  it  will  rein- 
fect the  enlarged  ulcers  left  after  the  sloughs  separate.  If  the  chancroidal  ul- 
ceration is  extensive  or  if  there  are  sinuses  or  if  there  are  severe  anal  lesions, 
it  is  best  to  give  the  patient  a  general  anesthetic,  that  sinuses  may  be  laid  open 
freely  and  all  lesions  carefully  cauterized.  After  cauterization,  there  is  left 
a  simple  ulcer  which  usually  heals  rapidly  under  the  ordinary  cleansing  and 
antiseptic  treatment  previously  given.  If  the  granulations  become  sluggish, 
they  may  be  stimulated  by  the  application  of  silver  nitrate  solution  (5%  to 
10%)  or  copper  sulphate  solution  (10%  to  25%).  The  copper  sulphate  is 
especially  indicated  where  there  is  any  hemorrhagic  tendency.  If  the  granu- 
lations are  persistently  unhealthy,  they  may  be  cleared  away  with  the  sharp 
curet  and  the  surface  then  stimulated  to  healthy  action,  as  above  indicated. 

The  treatment  of  chancroidal  adenitis,  and  of  suppurative  buboes  in  gen- 
eral, has  been  the  subject  of  much  thought  and  experimentation. 

Of  first  importance  is  prophylaxis.  The  most  certain  means  of  preventing 
a  bubo  is  to  secure  rapid  healing  of  the  genital  sore.  This  is  one  of  the  strong 
points  in  favor  of  cauterization  of  chancroids,  for  thorough  cauterization, 
probably  more  than  any  other  one  measure,  checks  the  infective  process  and 
causes  rapid  healing. 

When  soreness  in  the  groin  with  some  enlargement  of  the  glands  is  noticed, 
the  patient  should  be  put  to  bed  and  kept  there,  and  compresses  M^et  in  the 
lead  and  alum  lotion  should  be  applied  to  the  affected  region.  A  piece  of 
absorbent  cotton  is  moistened  with  this  solution  and  then  applied  over  the  af- 
fected glands  and  held  in  place  by  a  bandage  so  arranged  as  to  make  rather 
firm  pressure  on  the  glands.  A  "spiea"  bandage  is  the  form  usually  used. 
The  dressing  should  be  renewed  two  or  three  times  in  the  twenty-four  hours, 
depending  on  the  intensity  of  the  inflammation.  Spitschka,  who  originated 
this  treatment,  regards  it  as  by  far  the  most  effective  abortive  treatment  in 
the  first  stage  of  adenitis,  much  more  so  than  applications  of  tincture  of  iodine 
or  poultices  or  the  ice  bag.  Under  this  treatment  the  pain  usually  subsides 
rapidly,  and  frec[uently  suppuration  is  prevented.  If  dermatitis  results,  the 
solution  may  be  weakened  or  discontinued,  a  soothing  ointment  being  then 
applied. 

Inunction  of  half  a  teaspoonful  of  mercurial  ointment  over  the  tender 
glands  once  daily  for  a  few  days  is  another  measure  which  seems  to  prevent 
suppuration,  but  mercurialization  must  be  guarded  against.    Another  method 


478  DISEASES   OF    THE   EXTERNAL    GENITALS   AND   VAGINA 

much  used,  is  the  application  of  the  mercury,  belladonna  and  iodine  ointment. 
The  ointment  is  rubbed  in  over  the  swollen  glands,  then  cotton  is  applied, 
and  over  all  a  firm  spica  bandage.  The  bandage  should  be  applied  firmly 
enough  to  make  considerable  pressure  on  the  glands.  The  dressing  may  be 
changed  once  or  twice  daily. 

If  after  a  few  days '  trial  of  one  of  the  above  measures,  the  adenitis  is  still 
increasing,  the  time  for  intraglandular  injection  has  arrived.  Many  solu- 
tions for  injection  have  been  tried  with  benefit.  Probably  the  best  injection- 
solution  is  the-  1%  solution  of  benzoate  of  mercury,  recommended  by  Welan- 
der.  With  an  ordinary  hypodermic  syringe,  five  to  ten  drops  of  this  solu- 
tion are  injected  into  each  of  the  enlarged  glands,  the  skin  having,  of  course, 
been  thoroughly  disinfected.  The  needle  may  be  entered  at  several  points,  if 
necessary  to  reach  the  various  glands.  The  total  amount  of  solution  injected 
should. not  exceed  twenty  or  thirty  drops. 

The  injection  causes  considerable  reaction,  as  evidenced  by  pain  and 
swelling  and  some  fever.  After  two  or  three  days,  the  irritation  subsides  and 
usually  resolution  takes  place,  if  the  buboes  were  not  fiuctuating  at  the  time 
of  injection.  If  one  injection  is  not  suificient,  another  may  be  made  after  sev- 
eral days,  even  though  fluctuation  is  present. 

If  the  evidence  of  fluid  persists  several  days  after  all  irritation  from  the 
injection  has  subsided,  the  abscess  should  be  opened  by  incision  and  the  in- 
cision kept  open  by  a  strip  of  antiseptic  gauze,  and  the  cavity  treated  in  the 
ordinary  way  with  peroxide  and  bichloride  solution. 

Some  cases  presenting  fluctuation  have  been  cured  by  injection.  Even 
when  incision  later  is  necessary  the  injection  seems  to  be  beneflcial  in  three 
ways : 

a.  The  glands  opened  after  injection  rarely  show  chancroidal  ulceration, 
but  heal  as  simple  abscesses. 

b.  Complete  liquefaction  of  all  involved  tissues  is  more  frequent,  so  that 
deep  curetting  or  extirpation  of  partially  broken-do\^ai  glands  is  rarely  neces- 
sary. 

c.  Other  glands  are  seldom  involved  after  the  injection  of  those  first  af- 
fected, consequently  many  glands  are  saved  and  an  extensive  scar  avoided. 

The  most  certain  and  rapid  method  of  curing  a  chancroidal  bubo  in  an 
early  stage  is  to  completely  excise  the  affected  glands  and  close  the  wound 
immediately  by  sutures.  However,  only  a  small  proportion  of  patients  will 
submit  to  this  radical  treatment,  particularly  in  view  of  the  fact  that  many 
buboes  recover  without  suppuration.  Then  there  is  the  danger  of  the  general 
anesthetic,  slight  to  be  sure,  but  ever  present. 

After  the  bubo  has  resisted  abortive  measures  several  days,  suppuration 
is  very  probable  and  complete  extirpation  may  then  be  urged  with  more  force. 
Most  patients,  however,  prefer  the  less  radical  injection  method  and  some  ob- 
ject even  to  that,  insisting  on  simple  external  applications  to  relieve  the  pain 
and  incision  later  when  absolutely  necessary. 


SYPHILIS  479 

A  ichancroidal  sinus,  persisting  from  a  bubo,  may  be  injected  with  iodo- 
form in  glycerine  (10%)  once  daily,  after  washing  out  with  peroxide.  If  this 
does  not  cause  the  sinus  to  heal  it  may  be  curetted  with  a  small  curet  under 
cocaine  anesthesia.  If  it  still  persists  there  are  probably  broken-doAvn  glands 
that  must  be  completely  extirpated  under  a  general  anesthetic,  before  healing 
can  take  place. 

SYPHILIS 

OF  VuIjVA  and  Vagina 

Syphilis  is  a  general  infectious  disease,  characterized  by  an  initial  sore 
(the  point  of  entrance  of  the  infecting  germ)  and  by  general  secondary  mani- 
festations after  several  weeks  and  by  tertiary  lesions,  localized  in  various  parts 
of  the  body,  usually  only  after  several  years. 

The  infectious  agent  is  the  spirochete  pallida,  a  very  small  microbe  which 
is  found  in  all  lesions  (primary,  secondary  and  only  rarely  in  tertiary).  The 
demonstration  of  this  germ,  by  proper  staining  methods  or  by  examination  in 
the  dark-field,  makes  possible  a  positive  diagnosis  of  syphilis  at  once,  even 
in  the  primary  stage  and  long  before  the  clinical  evidences  appear.  The  posi- 
tive identification  of  this  infectious  germ  requires  considerable  bacteriologic 
experience,  hence  the  specimens  should  be  sent  to  a  pathologist. 

The  directions  for  preparing  specimens  are  as  follows: 

In  case  of  a  suspected  primary  lesion  (chancre),  wipe  the  surface  of  the 
ulcer  with  cotton  or  gauze  thoroughly,  avoiding  to  cause  bleeding.  From  the 
"irritation  serum"  which  results,  make  a  spread-preparation  on  a  slide  or 
cover-glass,  just  as  in  making  a  preparation  of  blood.  Half  a  dozen  speci- 
mens are  made  and  dried  and  then  packed  for  transmission. 

In  SECONDARY  LESIONS  (mucous  patches,  moist  papules,  dry  papules),  a 
spread-preparation  of  the  "irritation  serum,"  made  as  above  directed,  will 
usually  suffice  for  a  diagnosis.  A  negative  finding,  however,  does  not  cer- 
tainly exclude  syphilis.  Consequently,  to  make  the  diagnosis  certain,  a 
tissue  specimen  should  be  examined.  This  is  easily  secured  by  clipping  off  a 
small  papule.  Preserve  all  tissue  specimens  to  be  examined  for  the  spiro- 
chete pallida,  in  10%  formol  solution.  Specimens  preserved  in  alcohol  do  not 
stain  so  well. 

In  TERTIARY  LESIONS  Only  tissue  specimens  can  be  used  for  diagnosis, 
and  they  must  be  taken  from  the  capsule,  or  tissue  about  the  gumma.  The 
gummatous  material,  or  necrotic  material  in  the  center  of  a  "  gumma, ' '  is  not 
suitable  for  a  search  for  spirochetes. 

Syphilis  may  be  hereditary  or  acquired.  In  the  hereditary  form  the 
lesions  of  the  genitals  either  constitute  only  a  small  part  of  the  general  syph- 
ilitic picture,  as  in  the  severe  cases  leading  to  death  of  the  infant,  or  appear 
as  ordinary  tertiary  lesions  later  in  life.     Consequently  hereditary  syphilis 


480  DISEASES    OF    THE    EXTERNAL    GENITALS    AND   VAGINA 

requires  no  special  consideration  in  this  connection.  Acquired  syphilis  is  due 
to  inoculation  of  a  crack,  scratch  or  abrasion  with  secretion  from  a  syphilitic 
sore  or  with  syphilitic  blood. 

In  the  case  of  a  primary  sore  of  the  vulva  or  vagina,  there  has,  of  course, 
been  contact  of  the  genitals  with  the  syphilitic  virus,  either  by  sexual  inter- 
course, which  is  the  more  common  way,  or  by  contact  with  contaminated 
clothing  or  fingers  or  household  utensils  or  bath  room  articles  (particularly 
the  water-closet  seat  in  public  places).  In  the  case  of  secondary  or  tertiary 
lesions  of  the  genitals,  the  primary  lesion  may  have  been  on  the  genitals  or  on 
any  other  part  of  the  body. 

Pathology,  Symptoms,  Diagnosis 

Syphilis  of  the  vulva  or  vagina  may  appear  in  the  form  of  primary  or  sec- 
ondary or  tertiary  lesions. 

Primary  Lesions.  For  a  period  of  two  to  three  weeks  after  infection  with 
syphilitic  virus,  there  is  nothing  to  indicate  that  such  infection  has  taken 
place.  The  small  abrasion,  through  which  the  infection  took  place,  heals  in 
a  few  days  as  though  nothing  had  happened  and  there  is  apparently  no  morbid 
process  going  on  there.  This  is  known  as  the  "first  incubation  period."  In 
exceptional  cases  it  may  be  less  than  two  weeks  or  more  than  three  weeks, 
sometimes  extending  to  six  or  even  eight  weeks. 

At  the  end  of  the  incubation  period  a  papule  appears  at  the  point  of  in- 
fection. If  the  virus  entered  at  two  or  three  points,  there  may  be  a  like  num- 
ber of  lesions,  but  this  is  exceptional.  The  small  red  papule  is  the  usual 
form  which  the  initial  lesion  takes.  The  papule  may  be  decidedly  elevated 
and  pointed,  or  it  may  be  flat  and  scarcely  raised  above  the  surface,  but  in 
either  case  some  induration,  slight  at  first,  may  be  felt. 

If  this  papule  is  situated  on  the  external  surface  and  is  kept  dry,  it 
remains  simply  as  a  dry  papule  with  some  scaling  but  no  ulceration.  This 
form  of  primary  lesion  is  known  as  the  dry  scaling  papule.  It  enlarges 
peripherally  and  may  vary  in  size  from  a  pea  to  a  dime.  Exceptionally,  the 
fiat  papule  may  grow  to  the  size  of  a  silver  quarter. 

The  induration  also  increases,  and  at  the  end  of  a  week  or  ten  days  is 
characteristic.  The  best  way  to  feel  this  induration  is  to  grasp  the  lesion  be- 
tween the  thumb  and  finger  and  gently  squeeze  it  or,  more  accurately,  squeeze 
the  tissues  beneath  it.  The  induration  assumes  two  forms.  It  may  be  present 
as  a  thin  dense  layer  under  the  papule  or  ulcer.  When  grasped  as  just  indi- 
cated, such  form  of  induration  gives  the  sensation  of  a  small  piece  of  thick 
writing-paper  or  stiff  blotting-paper  lying  horizontally  under  the  lesion.  The 
margins  are  quite  distinct  and,  when  pressed,  the  plate  of  induration  can  be 
felt  to  bend  much  as  a  piece  of  blotting-paper  would.  This  is  called  ''parch- 
ment induration."  On  the  other  hand,  the  induration  may  be  present  as  a 
thick  rounded  mass,  occupying  the  base  of  the  papule  or  ulcer  and  extending 


SYPHILIS  481 

a  considerable  distance  below  it.  This  area  of  induration  is  in  the  form  of 
a  nodule  which  is  dense  and  firm  and  presents  distinct  outlines.  When  exam- 
ined by  grasping,  as  before  described,  it  gives  the  impression  of  a  piece  of 
cartilage  beneath  the  sore  and  is  known  as  ''cartilaginous  induration,"  called 
also  "nodular  induration." 

The  induration  of  a  syphilitic  chancre  disappears  very  slowly.  AVhen  Avell 
marked  it  persists  through  the  second  incubation  period,  i.e.,  until  the  de- 
velopment of  secondary  symjDtoms,  and  then  gradually  undergoes  involu- 
tion. As  a  rule,  the  primary  lesion  with  its  accompanying  induration,  disap- 
pears completely  within  six  to  eight  weeks  after  the  beginning  of  the  sec- 
ondaries. Frequently  some  induration  or  a  pigmented  spot  marks  the  cite 
for  several  months  longer,  and  occasionally  the  indurated  tissue  becomes 
somewhat  organized  and  persists  indefinitely  as  a  small  hard  nodule  of  scar- 
tissue. 

Another  form  of  primary  lesion  is  the  superficial  erosion.  This  is  noticed 
as  a  small  round  or  oval  red  spot  which  may  or  may  not  be  slightly  raised. 
The  center  is  often  slightly  depressed.  The  top  layers  of  epithelium  over  this 
spot  have  been  thrown  off,  forming  a  superficial  abrasion,  or  raw  place,  called 
an  erosion.  A  thin  gray  film  usually  occupies  the  center  of  the  lesion  and  in 
many  cases  covers  all  of  it.    The  characteristic  induration  is  present. 

A  third  form  of  initial  lesion  is  the  indurated  nicer.  If  either  the  dry 
papule  or  the  superficial  erosion  lose  all  their  epithelium,  so  that  granulation 
tissue  forms,  there  is  an  ulcer  with  an  indurated  base.  This  transformation 
is  especially  liable  to  take  place  when  the  lesion  is  kept  moist,  hence  it  is 
most  frequently  met  with  in  the  vagina  or  on  the  inner  surfaces  of  the  labia. 
It  may,  however,  occur  in  any  situation,  and  in  many  cases  the  ulcer  is  appar- 
ently present  almost  from  the  beginning.  This  indurated  ulcer  was  the  first 
form  of  primary  lesion  recognized  as  indicating  infection  from  syphilis,  and 
to  it  were  given  the  names  ''hard  chancre"  and  "hard  sore"  and  "liunterian 
chancre." 

Any  of  the  three  forms  of  primary  lesion  may  be  small  or.  large.  Unless 
accompanied  with  pus  infection,  they  give  rise  to  very  little  pain  or  disturb- 
ance, and  if  small  may  be  overlooked  entirely  by  the  patient.  Many  women 
presenting  unmistakable  evidences  of  syphilis  can  give  no  history  of  a  primary 
sore  because  it  escaped  their  notice.  This  is  especially  liable  to  occur  if  the 
lesion  is  situated  in  the  vagina.  Furthermore,  a  small  primary  lesion  in  the 
vagina  may,  after  a  short  time,  disappear  so  completely  that  even  the  physi- 
cian can  find  no  trace  of  it. 

There  is  a  fourth  form  of  primary  lesion,  and  that  is  the  mixed  sore.  By 
a  "mixed  sore"  is  meant  a  sore  with  a  double  infection — both  chancroidal  and 
syphilitic,  the  former  disease  being  manifest  first,  and  the  latter,  two  to  four 
weeks  later.  At  first  the  sore  is  apparently  an  ordinary  chancroid,  but  after 
two  or  three  weeks  the  sore  loses  its  chancroidal  characteristics,  induration 
appears  under  it  and  an  ordinary  hard  chancre  develops,  to  be  followed  by 


482  DISEASES   OF    THE   EXTERNAL   GENITALS   AND   VAGINA 

other  evidences  of  syphilis.  In  other  cases,  the  chancroidal  ulceration  heals 
during  incubation  of  the  syphilitic  germ,  but  at  the  end  of  that  period  the 
scar  becomes  indurated,  perhaps  ulcerated;  and  a  primary  syphilitic  lesion 
appears. 

A  primary  syphilitic  ulcer  does  not  present  the  angry  appearance  and  de- 
structive characteristics  of  the  chancroidal  sore.  It  is  apparently  a  much 
less  virulent  sore.  The  edges  are  not  undermined,  but  slope  inward,  there  is 
not  such  a  marked  zone  of  inflammatory  reaction,  and  the  ulcer  does  not 
spread  so  rapidly  nor  so  persistently.  It  is  more  indolent  and  frequently  is 
nearly  painless.  In  fact,  the  absence  of  pain,  such  as  would  ordinarily  be 
expected  from  the  size  and  location  of  the  sore,  is  one  of  the  striking  char- 
acteristics of  syphilis.  But  any  syphilitic  lesion  may  become  infected  with 
ordinary  pus  germs,  in  which  case  it  usually  becomes  painful.  The  primary 
sore  may  heal  within  a  week  or  two  after  its  appearance,  or  it  may  persist  all 
through  the  second  period  of  incubation,  which  usually  occurs  in  pregnant 
women. 

The  primary  syphilitic  lesion  of  the  external  genitals  is  accompanied  by 
enlargement  and  induration  of  the  inguinal  glands  on  the  same  side  as  the 
lesion.  This  enlargement  may  be  marked  or  it  may  be  slight,  but  it  is  always 
present.  It  begins  in  a  week  after  the  appearance  of  the  primary  lesion.  It  is 
due  to  an  indolent  inflammation  or  induration  of  the  glands.  Several  glands 
are  affected  and  they  may  be  felt  as  distinct  painless  nodules,  entirely  separate 
and  freely  movable.  Unless  there  is  a  mixed  infection,  with  chancroidal  virus 
or  with  ordinary  pus  germs,  the  glands  do  not  present  any  evidence  of  acute 
inflammation  and  there  is  no  suppuration. 

Secondary  Lesions.  On  the  vulva,  secondary  syphilis  usually  manifests 
itself  by  the  development  of  moist  papules,  called  also  "condylomata  lata" 
(Figs.  242,  243).  These  may  appear  any  time  during  the  first  twelve  months 
of  the  secondary  period.  The  syphilitic  condyloma  consists  of  a  slightly  ele- 
vated, flattened  area  from  which  part  of  the  epithelial  covering  has  been 
thrown  off.  It  may  be  any  size  from  the  head  of  a  pin  to  as  large  as  the 
thumb-nail.  There  are  usually  several  lesions  and  in  some  cases  dozens  of 
them.  The  individual  lesions  have  a  fairly  regular  circular  or  elliptical  out- 
line. Several  of  them  may  coalesce,  forming  large  irregular  infiltrated  patches 
(Fig.  242).  In  some  cases  there  is  a  slight  secretion,  and  all  of  them  are 
kept  moist  a  portion  of  the  time  by  the  secretion  from  the  vagina.  They  are 
not  painful  and  cause  very  little  disturbance,  except  when  irritated. 

When  the  vaginal  discharge  is  very  irritating,  some  of  the  lesions  may 
become  inflamed,  in  which  case  they  are  reddened  and  angry-looking  and 
painful.  When  inflamed,  the  thin  epithelium  may  be  lost,  giving  rise  to  an 
ulcer  which  may  involve  a  part  or  all  of  the  lesions.  Sometimes  abrasions 
on  the  lesions  are  caused  by  scratching. 

The  favorite  locations  for  the  moist  papules  or  flat  condylomata,  are  the 
labia  minora  and  the  inner  surfaces  of  the  labia  majora.    In  some  cases,  how- 


TREATMENT    OP    SYPHILIS  483 

ever,  they  cover  all  the  external  genitals  and  extend  even  on  the  adjacent 
surfaces  of  the  thighs  (Fig.  243). 

Associated  with  them  are  other  evidences  of  secondary  syphilis,  such  as 
a  general  eruption,  enlargement  of  the  inguinal  and  epitrochlear  and  post- 
cervical  glands,  persistent  sore  throat,  sores  in  the  mouth  and  loosening  of 
the  hair. 

Tertiary  Lesions.  Tertiary  syphilis  of  the  vulva  and  vagina  usually  pre- 
sents itself  in  the  form  of  persistent  and  destructive  ulceration.  When  occur-^ 
ring  in  the  vicinity  of  the  vestibule,  it  not  infrequently  leads  to  destruction 
of  the  urethra.  Its  victims  are  usually  in  a  state  of  poor  health  and  lowered 
vitality.  They  have  little  tissue  resistance,  hence  the  destructive  action  of  the 
ulcer.  Coincident  ulceration  of  the  rectum,  with  stricture  formation,  is  fre- 
quent. AVhen  syphilitic  ulceration  affects  the  upper  part  of  the  vagina  or 
the  cervix  uteri  it  may  be  mistaken  for  cancer. 

A  tertiary  syphilitic  ulcer  is  usually  indolent,  comparatively  painless  and 
persistent  in  spite  of  local  treatment.  There  are  usually  other  evidences  of 
tertiary  syphilis  or  a  history  of  previous  secondary  or  tertiary  symptoms.  The 
ulceration  heals  under  antisyphilitic  treatment,  provided  the  patient's  vital- 
ity is  not  so  lowered  that  the  normal  tissue  resistance  is  destroyed. 

The  diagnosis  of  tertiary  syphilitic  ulcer  is  made  principally  by  the  pres- 
ence of  other  evidences  of  syphilis,  by  the  exclusion  of  other  forms  of  chronic 
ulceration  (chancroid,  tuberculosis,  cancer),  by  the  effect  of  treatment  and 
by  the  Wassermann  reaction.  In  the  case  of  persistent  ulcer,  of  doubtful  char- 
acter, a  piece  of  the  margin  of  the  ulcer  should  be  excised  for  microscopic 
examination. 

Treatment 

A  patient  should  not  be  given  constitutional  treatment  for  syphilis  until 
the  diagnosis  is  positive.  As  a  rule  a  positive  diagnosis  before  the  appearance 
of  the  "secondaries"  is  not  possible  by  the  ordinary  clinical  evidences,  not 
even  by  the  Wassermann  reaction,  which  at  this  time  still  may  be  negative. 
By  bacteriologic  examination,  however,  a  positive  diagnosis  may  be  made  at 
once,  even  in  the  very  earliest  stage  of  the  primary  lesion,  when  typical  spiro- 
chetes are  present. 

When  the  diagnosis  is  thus  made  early,  it  is  recommended  by  some  author- 
ities that  the  primary  lesion  be  at  once  completely  excised — not  with  the  idea 
of  preventing  general  syphilis,  but  to  modify  it  and  lessen  the  effect  of  the 
succeeding  stages.  This  excision  treatment  of  the  primary  lesion  is  still 
experimental. 

Otherwise  the  only  treatment  that  the  primary  lesion  requires  is  local  cleans- 
ing and  antiseptic  measures,  such  as  are  recommended  under  Simple  Ulcer. 
The  secondary  and  tertiary  lesions  require  regular  constitutional  treatment 
for  syphilis,  i.e.,  salvarsan  (606),  or  mercury  in  the  secondary  stage,  iodides  and 
tonics  in  the  tertiary  stage  and  a  combination  of  the  two  in  the  intermediate  stage 


484  DISEASES    OF    THE    EXTERXAL    GEX^ITALS    AX'D   YAGIX-A 

(late  secondary  and  early  tertiary).  For  the  details  of  the  internal  treatment  of 
syphilis  the  reader  is  referred  to  ^vorks  treating  of  that  subject. 

The  local  treatment  for  the  secondary  and  tertiary  lesions  of  the  vulva 
and  vagina,  is  simply  cleansing  and  antiseptic  and  astringent,  i.e.,  the  same 
as  for  Simple  Ulcers.  Argyrol  (25%),  protargol  (10%),  silver  nitrate  (2% 
to  10%)  are  excellent  applications  for  mucous  patches.  Bichloride  solution 
(1-2000)  is  a  good  wash.  Calomel  as  a  dusting  powder  is  also  useful  in  re- 
lieving the  irritation.  These  applications  are  likewise  beneficial  in  tertiary 
ulcers.  For  cleansing  all  the  irregularities  of  a  deep  ulcer,  hydrogen  peroxide 
is  effective.  When  there  is  a  tendency  to  bleed,  copper  sulphate  solution 
(10%)  may  be  used. 

Kavogli  highly  recommends  emplastrum  hydrargyri  as  an  application  in 
tertiary  syphilitic  ulcerations.  Wash  the  ulcer  with  bichloride  solution  (1- 
2000)  and  then  apply  the  emplastrum  hydrargyri.  This  causes  temporary 
increase  in  the  discharge  due  to  the  breaking  down  and  discharge  of  the  un- 
healthy granulations  and  detritus  at  the  bottom  of  the  ulcer.  After  a  few 
applications  healthy  granulations  appear  and  healing  begins.  After  that  the 
ulcer  is  given  ordinary  antiseptic  treatment,  i.e.,  it  is  washed  with  bichloride 
solution  or  hydrogen  peroxide,  or  both,  and  then  dusted  with  an  antiseptic 
powder. 

TUBERCULOSIS  OF  VULVA 

Tuberculosis  of  the  vulva  is  the  term  applied  to  those  lesions  of  the  ex- 
ternal genitals  produced  by  tubercle  bacilli.  Tuberculosis  of  this  region  and 
other  forms  of  persistent  ^Tilvar  ulceration  were  formerly  described  together 
under  the  terms  "lupus  vulvae,"  "lupus  hypertrophicus, "  "lupus  perforans," 
"ulcus  rodens,"  "destructive  ulcer  of  vulva,"  and  "perforating  ulcer  of 
saliva."  As  the  pathology  of  the  various  forms  of  ulceration  was  gradually 
worked  out,  it  was  found  that  in  many  of  the  cases  of  destructive  ulceration, 
tubercle  bacilli  were  present.  The  tubercular  lesions  were  then  formed  into  a 
class  by  themselves  and  this  class  includes  a  large  number  of  the  cases  of 
persistent  ulceration  formerly  described  under  the  titles  above  mentioned. 

Tuberculosis  of  the  vulva  is  due  to  local  infection  with  the  tubercle  bacil- 
lus. The  infection  may  take  place  through  an  abrasion,  in  which  case  the  in- 
fecting germ  may  be  brought  to  the  abrasion  by  a  tubercular  discharge  from 
the  uterus  or  vagina,  or  possibly  by  coitus  with  a  husband  having  a  tubercu- 
lar lesion  of  the  genito-urinary  tract  or  by  fingers  or  clothing  infected  with 
tubercular  discharge  either  from  the  patient  or  from  some  other  person. 

On  the  other  hand,  tissues  may,  in  rare  cases,  be  infected  without  any 
break  in  the  epithelial  covering.  In  such  a  case  the  tubercle  bacilli  may 
come  by  way  of  the  blood  or  lymph. 

Tuberculosis  of  the  vulva  begins  as  a  small  nodule,  usually  situated  near 
the  meatus  or  the  clitoris  or  at  the  posterior  commissure.     It  may  be  of  a 


TUBERCULOSIS    OF    VULVA  485 

dusky  red  or  jjliiisli  color.  Microscopic  examination  of  such  a  nodule  shows 
the  usual  round  cell  infiltration,  the  necrotic  areas,  the  giant  cells  and  the 
tubercle  bacilli,  found  in  tubercular  lesions  elsewhere.  There  may  be  only  a 
single  nodule  or  there  may  be  many.  After  a  time  the  nodules  break  down 
and  form  small  ulcers.  The  ulcers  have  hard  margins  and  an  irregular  base 
and  are  very  liable  to  have  an  area  of  irregular  infiltration  about  them.  The 
ulcers  discharge  some,  and  this  discharge  may  or  may  not  show  tubercle 
bacilli.  As  the  ulcers  enlarge  they  coalesce,  forming  extensive  areas  of  ulcera- 
tion of  very  irregular  outline  (Fig.  202).  As  the  ulcer  extends  at  one  part 
it  may  heal  at  another,  giving  rise  to  much  scar  tissue.  By  gradual  contrac- 
tion the  scar  tissue  interferes  with  the  local  circulation  of  the  blood  and 
lymph  and  may  lead  to  marked  stasis  hypertrophy  and  induration  of  the 
labia  and  clitoris. 

Tubercular  ulcers  are  chronic  and  persistent  and  may  extend  deeper 
and  deeper  until  fistulous  openings  are  formed  into  the  rectum  or  bladder  or 
urethra,  hence  the  name  perforating  ulcer.  Even  when  adjacent  cavities 
are  not  opened,  the  ulcers,  in  conjunction  with  the  contracting  scar-tissue, 
may  form  sinuses  and  discharging  surfaces  extending  deeply  in  various  di- 
rections, and  sometimes  causing  perforations  through  the  labia. 

A  positive  diagnosis  requires  a  microscopic  examination.  In  a  doubtful 
case  the  crucial  test  of  the  character  of  the  ulceration  consists  in  finding  tu- 
bercle bacilli  in  the  secretion  or  in  demonstrating  the  characteristic  pathologic 
changes  in  a  specimen  of  tissue  removed  from  the  margin  of  the  ulcer. 

Treatment.  If  there  are  no  marked  tubercular  lesions  elsewhere,  the 
whole  infiltrated  area  should  be  excised  and  the  wound  closed  by  sutures. 
If  the  infiltration  can  not  be  excised,  the  ulcer  should  be  thoroughly  curetted 
and  then  deeply  cauterized  with  carbolic  acid  or  the  thermo-cautery.  If  the 
patient  does  not  wish  these  severe  measures,  the  surfaces  may  be  touched  fre- 
quently with  tincture  of  iodine  or  with  lactic  acid  and  then  powdered  with 
iodoform.  In  some  cases  the  use  of  these  substances  causes  healing.  At  the 
same  time  the  patient  should  receive  constitutional  treatment  for  tubercu- 
losis. If  any  new  areas  of  the  tubercular  process  crop  out  they  should  be 
given  the  treatment  found  etfective  with  the  first  lesion.  When  the  disease 
is  still  in  the  stage  represented  by  small  nodules,  the  following  treatment  is 
recommended  by  Unna.  A  number  of  the  nodules  are  punctured  with  an  acne- 
lance.  Then  a  small  shred  of  absorbent  cotton  is  moistened  in  a  mixture  of 
mercury  (one  part),  carbolic  acid  (four  parts)  and  alcohol  (twenty  parts), 
and  pushed  into  the  lance  opening  with  a  sharp-pointed  instrument  and 
turned  about  and  left  there  ten  or  fifteen  minutes.  In  three  to  five  days  the 
irritation  has  subsided  and  other  nodules  may  be  treated  in  the  same  Avay, 
and  thus  the  process  is  continued  until  all  traces  of  the  tubercular  infiltra- 
tion have  disappeared. 

For  tuberculosis  of  the  vulva  and  for  rodent  ulcer,  there  is  a  treatment 
which  promises  to  be  superior  to  any  other  yet  devised,  not  excepting  the 


486  DISEASES    OF    THE   EXTERNAL    GENITALS   AND   VAGINA 

knife ;  namely,  the  treatment  by  tlie  X-ray  and  by  the  Finsen  light.  In  super- 
ficial tuberculosis,  a  cure  is  almost  certain  and  with  comparatively  little 
disturbance  of  healthy  tissue.  In  both  of  these  affections  this  treatment  is  as 
a  rule  preferable  to  the  knife.  The  treatment  is  long  but  it  gives  better  re- 
sults, i.e.,  there  is  as  large  a  percentage  of  cures,  with  less  disfigurement  and 
with  practically  no  pain. 

TUBERCULOSIS   OF   VAGINA 

Tuberculosis  of  the  vagina  is  usually  secondary  to  tuberculosis  of  the 
uterus  and  tubes,  the  vaginal  surface  being  infected  from  the  tubercular  dis- 
charge from  above.  Some  cases  occur,  however,  in  which  there  is  no  tubercu- 
lar trouble  higher  in  the  genital  tract.  In  such  a  case  the  vaginal  tuberculosis 
may  be  due  to  sexual  intercourse  with  a  husband  having  tubercular  lesion  of 
the  genital  tract,  or  to  the  use  of  an  infected  douche-nozzle  or  to  the  exten- 
sion inward  from  tuberculosis  of  the  vulva. 

The  most  common  site  for  vaginal  tuberculosis  is  the  posterior  vaginal 
fornix,  which  region  comes  most  in  contact  with  the  uterine  discharges.  It  is 
supposed  that  the  resistance  of  the  vaginal  epithelium  must  be  lowered  by  an 
irritating  discharge  or  otherwise,  before  invasion  by  the  tubercle  bacillus 
can^  take  place.  The  first  manifestation  of  tuberculosis  of  the  vaginal  wall 
is  the  development  of  a  number  of  miliary  tubercles.  These  may  be  confined 
to  a  small  area,  for  example,  to  the  posterior  fornix,  or  may  appear  over  a 
large  part  of  the  surface  at  once. 

Each  miliary  tubercle  is  a  small,  raised,  grayish  or  yellowish  dot,  the  size 
of  a  millet  seed  or  smaller.  As  the  lesions  develop  they  break  down  and  form 
small  ulcers,  which  may  coalesce  and  form  ulcers  of  various  sizes  The  tuber- 
cular ulcer  has  a  punched-out  appearance,  the  edges  being  perpendicular,  and 
the  base  is  yellowish  gray  and  may  show  many  miliary  tubercles.  The  miliary 
tubercles  frequently  occur  in  large  numbers  in  the  hyperemic  zone  about  the 
ulcer. 

Symptoms  and  Diagnosis.  The  stage  of  ulceration  is  usually  the  time  at 
which  the  patient  consults  the  physician,  complaining  of  discharge  and  dis- 
comfort. Examination  reveals  the  suspicious  ulcer  or  ulcers  and  further  in- 
vestigation will  usually  show  tubercular  disease  of  the  uterus  or  tubes. 

The  discharge  from  a  tubercular  ulcer  contains  tubercle  bacilli,  but  some- 
times in  such  small  numbers  that  they  are  not  found  when  the  discharge  is 
stained  and  examined.  In  a  doubtful  case,  some  tissue  from  the  margin  of  the 
suspected  ulcer  may  be  sent  to  a  pathologist  for  examination.  In  such  a  speci- 
men, in  addition  to  the  tubercle  bacilli,  there  are  found  the  characteristic  giant 
cells  and  necrotic  areas.  Another  way  of  testing  for  tuberculosis  in  the  labora- 
tory, is  by  injecting  some  of  the  secretion  into  the  peritoneal  cavity  of  a 
guinea  pig,  where  it  causes  tubercular  peritonitis  with  characteristic  lesions. 


MALIGXAXT    DISEASE    OF    THE   VULVA  487 

Treatment.  The  treatment  is  the  same  as  that  described  under  tubercu- 
losis of  vulva. 

MALIGNANT  DISEASE  OF  THE  VULVA 

Carcinoma  and  sarcoma  may  affect  the  external  genitals.  In  this  situation 
they  are  distinguished  by  the  same  signs  that  characterize  them  elsewhere, 
namely,  progressive  induration,  ulceration  and  involvement  of  the  neighbor- 
ing lymph  glands.     Malignant  disease  of  the  external  genitals  is  rather  rare. 

Epithelioma  is  the  most  frequent  form.  This  begins  usually  on  the  lower 
portion  of  the  labium  majus  as  a  small  hard  nodule  with  a  bluish  tinge 
especially  about  the  edge.  The  nodule  grows  slowly  and  at  first  may  produce 
no  symptoms.  In  some  cases,  however,  even  from  the  first  there  is  severe 
pruritus.  After  a  time,  part  of  the  nodule  breaks  down,  forming  a  small  ulcer 
which  is  surrounded  by  an  area  of  induration.  There  is  a  watery  discharge 
sometimes  mixed  with  blood.  AVhen  occurring  about  the  meatus  it  sometimes 
causes  the  urethra  to  appear  as  a  firm  indurated  cylinder.  The  progress  of 
the  disease  is  now  more  rapid,  the  extension  being  usually  in  the  long  axis  of 
the  labium.  Later,  the  adjacent  surfaces  and  structures  become  involved.  A 
fungus  or  protruding  growth  may  appear.  Figs.  203,  204,  205,  251,  252  and 
253,  show  the  various  cases  of  epithelioma  of  vulva. 

The  inguinal  glands  become  enlarged  early,  at  first  simply  from  the 
lymphatic  enlargement  that  always  takes  place  when  there  is  inflammation  or 
persistent  irritation  of  the  genital  region.  Later  the  glands  become  mfil- 
trated  with  cancer  cells  and  often  greatly  enlarged.  In  the  latter  stage  the 
carcinomatous  glands  break  down  and  ulcerate  externally. 

Experience  has  sho^^ii  that,  unless  recognized  and  extirpated  very  early, 
the  disease  is  usually  incurable.  Its  duration  from  the  beginning  is  usually 
about  two  years. 

The  patient  may  suffer  from  burning  and  superficial  pain  in  the  early 
stages  and  later  there  may  be  severe  pain  from  iuA^olvement  of  the  deeper 
structures.  Carcinoma  of  the  clitoris  (Fig.  205)  has  been  observed  a  number 
of  times.  Frequently  it  is  melanotic.  A  rarer  location  for  cancer  is  the 
vulvo-vaginal  gland,  the  particular  form  of  growth  originating  here  being  the 
adeno-earcinoma  (Fig.  254).  In  all  of  these  forms  of  growth,  extirpation  in  a 
very  early  stage  gives  the  only  probability  of  cure.  Consequently,  in  the  case 
of  a  suspicious  ulcer  or  nodule  in  which  the  diagnosis  remains  doubtful  after 
careful  treatment  for  a  short  time,  a  piece  of  the  margin  of  the  area  should 
be  excised  for  microscopic  examination. 

Treatment.  Early  and  wide  excision  is  the  treatment  to  employ  when  the 
disease  is  operable.  Xo  time  should  be  wasted  with  X-ray  or  other  uncertain 
methods.  After  extirpation,  X-ray  or  radium  treatment  may  be  used  to  pre- 
vent recurrence. 

If  the  malignant  infiltration  has  gone  too  far  for  complete  removal,  palli- 


DISEASES    OF    THE    EXTERNAL    GENITALS   AND   VAGINA 

ative  measures  must  be  employed.  These  consist  of  general  sedatives  and 
local  applications  to  relieve  pain,  curetment  and  cauterization  of  the  ulcer, 
X-ray  or  radium  treatment  and  the  employment  of  the  various  measures  men- 
tioned under  simple  ulcer.  In  advanced  cases  there  is  so  much  destruction  of 
tissue  by  ulceration  that  it  is  difficult  to  keep  the  ulcerating  surface  clean 
and  free  from  odor.  Iodoform  and  charcoal,  half  and  half,  sprinkled  freely 
over  the  surface  and  covered  with  gauze,  aids  in  this.  The  salicylic  acid  and 
iodoform  powder  has  much  the  same  effect. 

In  the  inoperable  cases,  opium  will  be  required  sooner  or  later  to  dimin- 
ish suffering,  and,  when  needed,  it  should  be  given  freely  and  gradually  in- 
creased as  required  to  give  relief.  In  the  inoperable  cases,  particularly  the 
cases  of  sarcoma,  the  mixed  toxins  of  the  streptococcus  and  the  bacillus 
prodigiosus  (Coley's  toxins)  may  be  found  beneficial.  If  these  fail,  tlie 
growth  may  be  somewhat  retarded  by  repeated  injections  of  a  few  drops  of 
alcohol  in  various  parts  of  the  growth.  These  injections  may  be  repeated 
every  two  or  three  days  or  at  longer  intervals,  according  to  the  disturbance 
they  cause. 

MALIGNANT  DISEASE  OF  THE  VAGINA 

Carcinoma  of  the  vagina  is  usually  secondary  to  carcinoma  of  the  uterus 
or  rectum  or  bladder  or  external  genitals,  and  the  treatment  depends  on  the 
situation  and  extent  of  the  principal  lesion.  Primary  carcinoma  of  the  va- 
gina is  rare.  It  is  of  the  squamous-cell  variety  (epithelioma)  and,  according 
to  Pozzi,  it  occurs  in  two  forms. 

1.  As  a  papillary  growth.  This  form  usually  attacks  the  posterior  wall 
of  the  vagina,  making  its  appearance  as  a  broad-based  excrescence,  which  first 
invades  the  fornix  and  then  extends  downward  toward  the  vulva.  It  ap- 
pears, in  some  cases,  to  have  its  origin  in  the  neighborhood  of  plaques  of 
chronic  vaginitis. 

2.  Nodular  or  infiltrated  form.  This  appears  as  nodules  which  rapidly 
become  confluent.  The  growth  is  sometimes  localized  about  the  wall  of  the 
urethra,  giving  rise  to  a  well-defined  clinical  type  known  as  ''periurethral 
cancer,"    Ulceration  here  advances  rapidly. 

In  primary  cancer  of  the  vagina,  as  in  cancer  elsewhere,  a  positive  diag- 
nosis in  the  eary  stages  must  rest  upon  microscopic  findings  in  an  excised  piece. 
The  treatment  is  complete  extirpation,  if  seen  early  enough.  The  results  thus 
far  have  been  unsatisfactory.  There  is  usually  recurrence.  However,  it  is  prob- 
able that  the  adoption  of  recent  radical  operations  looking  to  the  extirpation, 
not  only  of  the  infiltrated  area  but  of  all  surrounding  tissues  likely  to  be  in- 
volved, will  give  much  better  results,  at  least  in  the  early  cases.  Also  by  spe- 
cial apparatus  X-ray  and  radium  treatment  may  aid  some  in  preventing  re- 
currence. 

Chorioepithelioma.     This  varietv  of  carcinoma  sometimes  occurs  in   the 


MALIGNANT   DISEASE    OF    THE    VAGINA 


489 


vagina,  representing  an  early  metastasis.  This  curions  form  of  tnmor  will  be 
considered  in  greater  detail  under  Malignant  Disease  of  the  Uterus.  It 
arises  from  chorionic  villi  and  may  develop  after  normal  parturition  or  after 
abortion  or  after  mole-pregnancy.  It  usually  develops  in  the  uterus,  but  oc- 
casionally one  of  the  chorionic  villi  transported  to  the  vagina  (pieces  of 
chorionic  villi  are  normally  transported  to  A^arious  parts  of  the  body  in  prob- 
ably all  pregnancies)  takes  on  the  peculiar  change  and  forms  a  malignant 
grovi^th.  As  it  grows,  it  breaks  into  the  veins,  causing  miniature  hematomata 
in  the  vicinity.  As  this  kind  of  tumor  usually  causes  metastases  through 
the  body,  with  rapid  death,  it  is  important  to  recognize  and  remove  it  at  the 
earliest  possible  moment.     Since  such  a  growth  in  the  vagina  or  in  the  vulva 


■^K 


Fig.   459.      Sarcoma    of    V^agina    in    a    Child, 
power. 


Low 


^e  .'« - 


-,-,    .»•  -      m  »■'€ 


,   ♦ir* 


^^^^**^*^  **='•' 

:.:••'>-•:'!. 


Fig 


460.      Same    specimen    as    Fig.    459.      High 
power. 


is  usually  metastatic  from  a  similar  growth  in  the  uterus,  the  condition  of  the 
uterus  should,  be  investigated. 

Sarcoma.  One  form  in  which  sarcoma  of  the  vagina  occurs,  is  as  a  dif- 
fuse infiltration  and  degeneration  of  the  lining  membrane.  This  is  the 'form 
sometimes  found  in  young  children  (Figs.  456,  460).  It  occurs  most  frequently 
in  the  posterior  vaginal  wall.  It  begins  as  a  small  indurated  area  which 
slowly  increases  in  size.  After  a  time  the  epithelium  covering  the  area  is 
lost  and  an  ulcer  forms.  The  ulcer  bleeds  easily  and  is  surrounded  by  an 
area  of  induration.  A  large  part  of,  or  even  the  entire  circumference  of  the 
vagina  may  become  involved  in  the  sarcomatous  infiltration,  which  may  be 
mistaken  for  carcinoma  or  tuberculosis. 


490  DISEASES   OF    THE   EXTERNAL   GENITALS   AND   VAGINA 

The  symptoms  of  sarcoma  of  the  vagina  are  leiicorrhea,  hemorrhage,  pain 
and  obstruction  of  the  vagina  by  the  infiltration.  Slight  hemorrhage  may 
appear  in  the  early  stages,  particularly  after  coitus  or  exertion.  In  the  late 
stages,  profuse  hemorrhages  occur  and  there  is  also  a  muco-purulent  or  wa- 
tery discharge  that  may  cause  pruritus.  The  pain  is  slight  at  first  but  grad- 
ually increases  in  severity.  It  is  usually  worse  at  night.  Examination  re- 
veals a  nodular  tumor  or  an  area  of  induration  or  ulceration  and  more  or 
less  narrowing  or  obstruction  of  the  vagina.  For  a  positive  diagnosis  of  the 
nature  of  the  growth  a  microscopic  examination  of  a  section  of  tissue  is  nec- 
essary.    The  treatment  is  the  same  as  for  carcinoma. 

ULCUS  RODENS  VULVAE 

From  the  large  group  of  affections  formerly  classified  roughly  under 
the  terms  ''rodent  ulcer,"  ''lupus,"  " esthiomene, "  "perforating  ulcer"  and 
similar  names,  there  have  been  cut  out  distinct  classes,  until  now  these  cases 
are  pretty  well  divided  up  as  syphilis,  tuberculosis  (to  which  the  term  lupus 
is  now  restricted)  and  malignant  disease,  with  special  characteristics  for  each. 
There  still  remain,  however,  certain  persistent  destructive  ulcers,  but  rarely 
seen,  whose  etiology  is  not  definitely  known,  and  consequently  whose  etio- 
logic  classification  can  not  yet  be  positively  made. 

They  constitute  a  class  by  themselves  and,  in  the  absence  of  more  definite 
information,  are  very  appropriately  designated  by  the  non-committal  term 
"ulcus  rodens"*  (gnawing  ulcer). 

Rodent  ulcer  of  the  vulva  may  be  defined  as  a  destructive  chronic  ulcer 
that  is  neither  syphilitic  nor  tubercular  nor  malignant. 

The  affection  occurs  almost  exclusively  in  prostitutes  and  is  apparently 
due  to  the  combination  of  depressed  general  health  and  the  chronic  irritation 
of  frequent  coitus  (traumatism)  and  varied  and  repeated  infections  and  un- 
cleanliness.  The  post-syphilitic  state  is  undoubtedly  an  important  etiologic 
factor  in  many  cases,  the  effect  being  due  probably  to  the  deteriorated  gen- 
eral health  and  lowered  tissue  resistance.  Real  syphilitic  lesions,  i.  e.,  those 
yielding  to  antisyphilitie  treatment,  are  excluded  by  the  terms  of  the  defini- 
tion of  rodent  ulcer,  the  clinical  differentiation  being  aided  by  the  thera- 
peutic test.  The  cicatricial  tissue  which  forms  around  and  under  the  ulcer- 
ated area  tends  further  to  interfere  locally  with  nutrition. 

The  pathologic  changes  are  those  found  in  chronic  ulceration  with  cica- 
tricial change,  but  without  any  of  the  special  characteristics  found  in  syph- 
ilitic, tubercular  or  malignant  ulcers.  There  is  the  granulating  surface,  the 
round-cell  infiltration  and  the  connective  tissue  hyperplasia.  The  ulceration 
often  extends  deeply  into  the  structures  in  various  directions  and  causes 
perforations  and  fistulae.    As  it  spreads  in  one  part  it  heals  in  another,  thus 


*This  must  not  be  confounded  with  the  "ulcus  rodens"  of  the  face,   which   is  a  definite  and  peculiar 
variety  of  epithelial   cancer. 


ULCUS    RODENS   VULVAE  491 

forming  scar-tissue.  The  contraction  of  this  scar-tissue  and  of  tlie  inflam- 
matory infiltration  under  the  ulcer  causes  more  or  less  interference  with  the 
lymph  circulation.  If  the  trouble  persists  for  years,  as  it  sometimes  does, 
there  is  very  likely  to  be  stasis  hypertrophy. 

Symptoms  and  Diagnosis.  The  patient  complains  usually  of  leucorrhea 
and  of  burning  on  urination  and  of  pain  on  coitus.  There  are  frequently 
evidences  of  irritation  of  the  bladder  or  of  the  rectum.  If  the  ulcer  has 
penetrated  deeply  enough  there  may  be  incontinence  of  urine  or  feces.  In 
some  cases  there  is  pain  on  walking  or  sitting,  while  in  other  cases,  even  with 
extensive  ulceration,  the  patient  has  but  little  pain.  In  many  cases  the  ul- 
ceration is  accompanied  by  stasis  hypertrophy,  and  in  such  cases  there  is 
nearly  always  considerable  skin  irritation.  This  is  increased  by  uncleanli- 
ness  and  by  the  decomposition  of  the  discharge  in  the  folds  and  depressions 
of  the  hypertrophied  structures. 

Examination  shows  the  ulceration,  with  or  without  stasis  hypertrophy. 
A  common  site  for  the  ulceration  is  about  the  vestibule  and  extending  up  into 
the  vagina.  In  some  cases  it  extends  deeply  into  the  urethra,  separating  the 
lower  urethral  wall  so  that  it  is  simply  a  flap,  which  falls  away  from  the  up- 
per wall.  This  destructive  ulceration  may  extend  to  the  neck  of  the  bladder 
and  cause  incontinence  of  urine.  If  the  ulceration  appears  at  the  posterior 
part  of  the  vulva  it  may  penetrate  into  the  rectum  and  cause  a  recto-vaginal 
fistula. 

In  the  examination,  it  is  important  to  separate  the  swollen  structures 
and  trace  the  ulcer  in  all  its  ramifications.  Sometimes  there  are  two  or  more 
ulcerated  areas,  and  also  spots  of  dermatitis  due  to  the  irritation  of  the  dis- 
charge. If  the  manipulations  cause  too  much  pain  to  permit  of  a  thorough 
examination,  apply  some  20%  cocaine  solution  to  the  painful  areas.  Rodent 
ulcers  usually  bleed  but  little  from  the  ordinary  manipulations — not  nearly 
so  frequently  nor  so  freely  as  malignant  ulcerations. 

From  rodent  ulcer  we  must  distinguish  the  simple,  chancroidal,  syph- 
ilitic, tubercular  and  malignant  ulcers. 

In  simple  ulceration,  there  is  usually  some  cause  apparent,  and  the  ulcer 
heals  promptly  on  removal  of  the  cause  and  the  maintenance  of  cleanliness 
and  the  use  of  some  mild  antiseptic  or  astringent. 

In  chancroid,  the  ulcer  is  acute  and  presents  the  characteristics  previ- 
ously described  for  chancroid,  and  there  may  be  a  history  of  suspicious  coitus 
followed  in  a  few  days  by  the  painful  ulcer  which  rapidly  enlarges.  Cauter- 
ization and  the  other  treatment  recommended  for  chancroid  leads  to  prompt 
healing. 

Tertiary  syphilis  often  leads  to  destructive  ulceration  which  very  much 
resembles  rodent  ulcer.  But  there  are  usually  other  evidences  of  active  syph- 
ilis,  and  the  lesion  is  much  benefited  by  antisyphilitic  treatment. 

Tuberculosis  of  the  vulva,  in  some  cases,  causes  deep  and  persistent  ul- 
ceration which  is  much  like  rodent  ulcer.    But  the  special  characteristics  given 


492  DISEASES    OF    THE    EXTERNAL    GENITALS    AND    VAGINA 

under  tubercular  ulcer  are  present,  also  microscopic  examination  of  excised 
tissue  or  of  pus  and  scrapings  from  the  ulcer  will  show  the  trouble  to  be  tu- 
bercular. 

Malignant  disease  is  characterized  by  the  tendency  to  bleed  on  slight 
manipulation  and  by  an  area  of  induration  about  the  ulcer.  In  a  doubtful 
case  a  piece  of  the  margin  of  the  ulcer  should  be  excised  under  cocaine  for 
microscopical  examination. 

Treatment.  The  measures  recommended  under  simple  ulcers  should  be 
'  carried  out  and  should  be  supplemented  by  general  tonic  treatment  to  build 
up  the  tissue  resistance.  In  addition  to  this,  practically  every  case  of  this 
kind  should  receive  a  thorough  course  of  iodides,  both  for  diagnostic  pur- 
poses end  for  therapeutic  effect.  Very  few  cases  of  rodent  ulcer  are  much 
benefited  by  the  iodides  but  occasionally  one  is  considerably  benefited.  Other 
measures  are  mild  cauterizations,  deeper  cauterization  and  other  measures 
mentioned  under  chancroid.  The  X-ray  treatment  sometimes  produces  prompt 
healing.  A  very  important  point  in  the  treatment  is  rest  of  the  parts.  To  se- 
cure this  there  must  be  no  sexual  intercourse  and  no  unnecessary  walking 
or  standing. 

URETHRITIS 

Inflammation  of  the  urethra  and  also  of  the  urethral  ducts  ("Skene's 
glands)  has  already  been  considered,  under  Gonorrhea. 

PERIURETHRAL  ABSCESS 

This  term  is  applied  to  an  abscess  situated  outside  of  the  urethra  but  due 
to  infection  from  the  urethra.  It  usually  lies  between  the  urethra  and  va- 
gina. The  pocket  of  pus  may  or  may  not  communicate  with  the  urethra.  This 
condition  is  kno^^^l  also  as  ''urethrocele,"  "sacculation  of  urethra,"  "sinus 
of  urethra,"  "urethral  diverticulum"  and  "suburethral  abscess." 

Etiology  and  Pathology.  In  some  cases  there  is  infection  of  a  urethral 
gland  which  becomes  somewhat  obstructed  and  dilated  with  pus  and  is  ac- 
companied with  considerable  inflammation  and  infiltration  and  pus  formation 
outside  the  gland.  In  other  eases  there  is  probably  first  either  a  congenital 
cyst  or  a  cyst  formed  by  obstruction  of  the  duct  of  one  of  the  urethral  glands 
which  becomes  markedly  dilated  by  accumulating  secretion.  Later  there  is 
infection  of  the  cyst  by  rupture  or  otherwise,  and  consequent  abscess.  It  is 
supposed  also  that  injuries  in  labor  may  lead  to  localized  dilation,  sacculation 
and  suppuration. 

In  either  case,  as  the  collection  of  fluid  increases  in  size  a  swelling  appears 
in  the  anterior  vaginal  wall  below  the  urethra  (Fig.  266).  In  some  eases  the 
vaginal  wall  over  the  swelling  is  normal,  while  in  other  cases  there  is  much 
infiltration  and  thickening  and  induration.     The  abscess  frequently  ruptures 


PERIURETHRAL   ABSCESS  493 

into  the  urethra  and  empties  itself  incompletely.  It  may  continue  for  weeks 
or  months  partially  filled  with  pus  and  decomposing  urine,  and  discharging 
through  a  small  opening.  In  other  cases  there  seems  little  or  no  active  in- 
flammation and  no  discharging  sinus,  simply  a  collection  of  fluid  resembling 
a  cyst.  In  such  a  case  there  may  be  simply  a  retention  cyst  without  infection 
or  there  may  have  been  an  infection  that  died  out  without  forming  pus. 

Symptoms  and  Diagnosis.  When  there  is  an  acute  abscess,  there  are  all 
the  ordinary  evidences  of  inflammation  with  urethral  irritation  added,  causing 
frequent  painful  urination.  In  some  cases  there  still  remain  evidences  of  the 
urethritis  that  was  responsible  for  the  periurethral  infection.  There  is  a  red- 
dened tender  indurated  swelling  of  the  anterior  vaginal  wall  under  the  urethra. 
The  swelling  and  induration  may  be  diffuse  or  circumscribed.  If  a  collection  of 
pus  of  any  size  has  formed  there  will  be  fluctuation.  If  the  abscess  has  opened 
into  the  urethra,  pressure  on  the  swelling  will  cause  pus  to  flow  into  the  ure- 
thra and  out  at  the  meatus.  Sometimes  a  probe  may  be  passed  from  the 
meatus  through  the  opening  into  the  periurethral  cavity  (Fig.  267). 

When  the  acute  inflammation  has  subsided,  there  is  left  simply  a  swell- 
ing with  considerable  urethral  irritation.  If  the  cavity  is  discharging  into  the 
urethra,  the  swelling  may  have  largely  disappeared.  Such  a  pocket  outside 
the  urethra  may  cause  urethral  and  bladder  disturbance  for  months  with- 
out the  real  condition  being  suspected,  particularly  if  there  is  simply  a  sinus 
or  small  pocket  with  but  little  swelling.  It  may  keep  up  a  urethritis  indefi- 
nitely and,  if  gonorrheal,  the  patient  is  capable  of  communicating  the  infec- 
tion as  long  as  the  sinus  exists.  An  exacerbation  of  the  inflammation  with 
acute  symptoms  may  come  on  at  any  time.  Such  a  periurethral  sinus  may  bs 
the  unsuspected  cause  of  the  persistent  presence  of  pus  in  the  urine. 

Treatment.  The  treatment  for  this  condition  is  to  drain  the  cavity  at  the 
most  dependent  part,  that  is,  where  it  comes  closest  to  the  vaginal  wall.  At 
this  point  a  large  opening  should  be  made  and  the  incision  should  be  kept 
open  by  gauze  packing  or  a  drainage  tube  until  the  cavity  heals  from  the  bot- 
tom. The  abscess  cavity  should  be  washed  out  with  hydrogen  peroxide  and 
given  the  usual  treatment  of  a  suppurating  cavity.  When  drainage  is  free  be- 
low, the  opening  into  the  urethra  usually  closes  promptly. 

When  there  is  only  a  collection  of  fluid  without  active  inflammatory  symp- 
toms, the  small  cysts  thus  formed  may  be  extirpated.  In  extirpation  of  such 
a  mass,  care  should  be  exercised  not  to  dissect  too  close  to  the  urethra  nor  to 
the  sphincter  at  the  neck  of  the  bladder.  In  either  situation  it  is  better  to 
leave  part  of  the  cyst  wall  than  to  injure  the  important  structures  adjacent 
thereto.  When  there  is  simply  a  sinus  or  small  pocket  communicating  with 
the  urethra  by  a  fairly  large  opening  near  the  meatus,  the  plan  may  be  tried 
of  treating  the  cavity  with  various  antiseptics  such  as  hydrogen  peroxide, 
iodoform  in  glycerine  (10%)  or  silver  nitrate  solution  {y2%  to  2%),  injected 
into  the  cavity  by  way  of  the  meatus  through  a  small  tube  such  as  the  Eusta- 
chian catheter.  If  this  fails,  then  the  external  incision  and  drainage  is  to  be 
employed. 


494  DISEASES    OF    THE    EXTERNAL    GENITALS   AND   VAGINA 

PROLAPSE  OF  URETHRAL  MUCOSA 

This  affection  is  known  also  as  ''procidentia  urethrae."  It  consists  of  a 
prolapse  of  the  urethral  mucous  membrane,  accompanied  by  more  or  less  pro- 
liferation of  the  submucous  connective  tissue. 

Symptoms  and  Diagnosis.  The  red  projecting  membrane  surrounds  the 
meatus  (Fig.  264).  It  often  bleeds  easily  and  is  somewhat  sensitive  to  the 
touch,  though  not  nearly  so  sensitive  as  a  caruncle.  It  usually  gives  rise  to 
considerable  irritation,  with  frequent  painful  urination  and  some  discharge. 
It  is  distinguished  from  polypus  and  caruncle  by  the  fact  that  it  surrounds, 
or  almost  surrounds,  the  meatus. 

Marked  prolapse  of  the  urethral  mucosa  is  not  a  common  affection,  though 
slight  gaping  of  the  urethra,  through  which  the  mucous  membrane  may  be 
seen,  is  very  common  in  women  who  have  had  urethritis  or  have  passed 
through  several  labors. 

Treatment.  If  symptoms  are  absent  or  slight,  no  treatment  is  necessary. 
If  the  prolapse  is  marked  enough  to  be  troublesome,  the  part  may  be  cocain- 
ized, or  the  patient  anesthetized,  and  the  redundant  portion  of  mucous  mem- 
brane excised  and  the  wound  closed  by  sutures.  It  is  convenient  to  pass  the 
sutures  first,  then  excise  the  tissue,  then  tie  the  sutures.  This  prevents  the 
inner  edge  from  retracting  out  of  reach.  The  sutures  should  be  placed  close 
enough  together  to  close  the  wound  and  prevent  hemorrhage. 

Another  good  method  of  excision  is  to  begin  at  one  side  and  divide  the 
tissues  for  a  short  distance  and  immediately  close  the  resulting  wound  by 
suture,  continuous  or  interrupted  as  preferred.  Another  portion  is  then  di- 
vided and  the  wound  closed  as  before.  This  process  is  continued  until  the 
redundant  tissue  is  removed  all  the  way  around.  This  prevents  hemorrhage, 
prevents  retraction  and  secures  good  approximation.  Clean  excision  with  the 
knife  or  scissors  followed  by  immediate  suture  of  the  wound  is  decidedly  pref- 
erable to  cautery  amputation.    Fine  catgut  is  the  preferable  suture  material. 

URETHRAL  CARUNCLE 

Urethral  caruncle  is  a  small  papillary  growth  occurring  about  the  mea- 
tus, most  frequently  near  the  lower  portion.  It  is  usually  very  sensitive  and 
often  gives  rise  to  excruciating  pain  on  urination.  It  is  knovai  also  as  "ir- 
ritable caruncle"  and  "urethral  angioma."  The  cause  of  urethral  caruncle 
is  not  known.  Probably  chronic  inflammation  of  Skene's  glands  has  some  in- 
fluence in  its  causation,  as  it  usually  occurs  in  the  neighborhood  of  the  gland 
openings.  Inflammation  of  the  urethra,  particularly  gonorrheal  inflammation, 
is  supposed  to  be  a  causative  factor. 

The  little  tumor  is  essentially  a  vascular  growth.  Skene,  who  made  a  spe- 
cial study  of  urethral  neoplasms,  applied  to  caruncle  the  term  "papillary  poly- 
poid angioma"  and  gave  the  following  description.     "It  consists  of  a  bunch 


UKETHRAL    CARUNCLE  495 

of  dilated  capillaries,  set  in  a  moderately  dense  stroma  of  connective  tissue, 
covered  with  mucous  membrane  which  has  the  usual  pavement  epithelium.  One 
case,  however,  is  recorded  where  the  pavement  was  replaced  by  columnar  epi- 
thelium. The  vessels  are  greatly  dilated  and  in  some  cases  very  tortuous, 
while  in  others  less  so." 

The  growth  is  seen  as  a  deep  red  mass  at  the  meatus  (Fig.  265)  or  just 
Tvithin  the  canal.  It  is  sensitive  wdien  touched  and  may  bleed  easily  on  manip- 
ulation. It  may  have  a  distinct  pedicle  or  a  broad  base.  Usually  there  is  but 
one  growth,  but  sometimes  there  are  two  or  more. 

Symptoms  and  Diag-nosis.  The  principal  symptom  is  pain  on  urination. 
It  may  be  slight  or  it  may  be  very  severe.  In  some  cases  the  pain  is  so  trou- 
blesome that  the  patient  will  hold  the  urine  as  long  as  possible,  to  avoid  the 
suffering  caused  by  passing  it.  AValking  may  cause  pain  as  may  also  pressure 
of  any  kind,  even  contact  of  the  clothing.  Irritability  of  the  bladder,  as  in- 
dicated by  frequent  urination,  is  usually  present.  Occasionally  retention  of 
urine  is  caused  by  reflex  spasm.  Pain  and  hemorrhage  may  be  caused  by  sex- 
ual intercourse,  and  in  some  cases  coitus  is  impossible.  The  patient's  general 
health  necessarily  suffers  from  the  constant  irritation  and  she. becomes  nerv- 
ous, irritable  and  despondent. 

Polypi  of  the  urethral  mucous  membrane  and  prolapsed  mucous  mebrane 
differ  from  caruncle  in  being  less  vascular  and  less  sensitive.  Also,  polypi 
are  attached  higher,  while  in  prolapse  of  the  mucous  membrane  the  base  of 
the  mass  includes  the  larger  part,  if  not  all  of  the  circumference  of  the  meatus 
(Fig.  264).  ■  ' 

Treatment.  The  treatment  for  caruncle  is  removal.  First  apply  a  small 
piece  of  absorbent  cotton  soaked  in  cocaine  solution  (20%)  and  leave  in  place 
five  minutes.  Then  with  a  hypodermic  syringe  inject  several  drops  of  a  weaker 
cocaine  solution  (^'2%)  under  the  base  of  the  growth  and  wait  a. few  minutes 
longer.  Then  clip  the  growth  off  with  scissors.  All  the  abnormal  tissue  must 
be  removed.  Then  introduce  one  or  more  fine  catgut  sutures,  close  the  wound 
and  stop  the  hemorrhage. 

If  the  base  is  small  and  the  resulting  wound  slight  and  without  much 
hemorrhage,  it  may  be  simply  touched  with  carbolic  acid  or  liquor  ferri  sub- 
sulphatis,  no  sutures  being  needed.  When  the  growth  has  a  broad  base  and 
the  patient  is  very  nervous  or  hysterical  it  may  be  necessary  to  give  a  general 
anesthetic.  In  some  cases,  anesthesia  is  required  for  other  reasons,  for  ex- 
ample, a  thorough  pelvic  examination  or  curetment  or  repair  of  pelvic  floor, 
and  in  such  a  case  the  caruncle  may  be  taken  care  of  at  the  same  time.  The 
urethral  and  bladder  irritation  usually  subsides  rapidly  after  the  growth  is 
removed. 

While  the  patient  is  waiting  for  operation,  some  temporary  relief  may  be 
given  by  the  frequent  application  of  cocaine  solution  (5%  to  10%). 


496  DISEASES    OF    THE    EXTERNAL    GENITALS    AND   VAGINA 

INFLAMMATION  OF  VULVO-VAGINAL  GLAND 

Inflammation  of  the  duct  of  the  vulvo-vaginal  gland  and  of  the  gland 
proper,  has  been  considered  under  Gonorrhea.  Inflammation  in  this  gland 
of  Bartholin  is  sometimes  referred  to  as  "Bartholinitis." 

ABSCESS  OF  VULVO-VAGINAL  GLAND 

The  cause  is  infection  with  the  gonococcus  or  the  ordinary  pus  germs.  The 
flrst  is  by  far  the  more  frequent,  and  the  gonorrheal  inflammation  often  per- 
sists in  the  gland  long  after  the  vaginal  inflammation  has  disappeared. 

The  infection  enters  at  the  mouth  of  the  duct  and  progresses  along  the 
duct  to  the  gland  proper.  The  secretion  of  the  gland  is  increased,  the  duct 
becomes  obstructed  and  a  collection  of  pus  forms,  distending  the  gland  and 
IDointing  in  the  direction  of  least  resistance.  Sometimes  the  duct  alone  is  in- 
volved, the  gland  proper  escaping.  This  is  indicated  by  the  swelling  being 
small  and  confined  to  the  region  of  the  duct. 

Symptoms  and  Diagnosis,  The  symptoms  are  a  painful  swelling  at  the 
s:ide  of  the  vaginal  opening  with  some  fever.  Examination  reveals  a  swelling 
the  size  of  a  small  egg  situated  in  the  tissues  at  one  side  of  the  vaginal  orifice 
and  projecting  beyond  the  median  line  (Figs.  245,  246).  The  swelling  is  ten- 
der on  pressure  and  is  red  and  hot.  Fluctuation  is  distinct  and  the  fluid  seems 
near  the  surface.  The  orifice  of  the  duct  may  be  seen,  but  a  probe  will  not 
enter  the  gland  because  the  duct  is  obstructed.  If  the  obstruction  is  so  slight 
that  it  gives  way  before  the  probe,  then  pus  is  discharged  through  the  duct. 

The  following  conditions  may  be  confounded  with  abscess  of  the  vulvo- 
vaginal gland. 

Cyst  op  Vulvo-Vaginal  Gland.  This  is  a  chronic  affair,  the  patient 
usually  giving  a  history  of  the  swelling  having  been  there  for  a  long  time  and 
the  inflammatory  signs  (heat  and  pain  and  redness)  are  absent. 

Pudendal  Hernia.  This  must  always  be  taken  into  consideration  in  deter- 
mining the  character  of  a  swelling  of  the  vulva.  Hernia  presents  one  or  more 
of  the  hernial  signs,  such  as  impulse  on  coughing,  reducibility,  intestinal  ob- 
struction, resonance  on  percussion.  The  first  evidence  of  hernia  is  usually  no- 
ticed at  once  after  some  straining  effort  or  injury,  much  more  promptly  than 
either  abscess  or  cyst  would  appear. 

Tumor  of  Labia.  This  differs  from  abscess  in  the  absence  of  inflammation 
and  fluctuation,  in  growing  slowly  and  in  presenting  the  signs  that  distinguish 
the  various  kinds  of  vulvar  tumors. 

Treatment.  Open  the  abscess  freely  by  an  incision  Avhere  the  pus  is  near- 
est the  surface,  wash  out  the  cavity  with  hydrogen  peroxide  and  pack  with 
antiseptic  gauze.  The  wound  should  be  dressed  the  next  day  and  as  frequently 
thereafter  as  is  necessary  to  keep  it  clean.  Care  must  be  taken  that  a  good- 
sized  piece  of  gauze  projects  into  the  cavity,  that  the  edges  of  the  incision  may 


SINUS    OF    VULVO-VAGINAL    GLAND  497 

be  kept  separated  until  the  cavity  granulates  from  the  bottom.  If  the  in- 
cision into  the  abscess  is  not  made  when  the  patient  is  first  seen,  but  is  post- 
poned to  another  day,  much  relief  in  the  meantime  may  be  obtained  from  the 
application  of  a  hot  poultice.  Direct  the  patient  to  take  a  large  piece  of  ab- 
sorbent cotton,  wring  it  out  of  very  hot  water  and  apply  it  immediately  to 
the  inflamed  structures  and  cover  it  Avith  a  piece  of  oiled-silk.  This  hot  moist 
dressing  may  be  held  in  place  with  a  T-bandage.  It  may  be  renewed  as  soon 
as  it  begins  to  cool,  if  the  pain  is  troublesome. 

SINUS  OF  VULVO-VAGINAL  GLAND 

In  many  cases  of  abscess  of  the  gland,  after  the  pus  is  discharged  the 
cavity  closes  entirely  and  there  is  permanent  cure.  In  other  cases  a  sinus 
persists,  giving  rise  to  a  constant  slight  discharge.  The  outer  end  of  the 
sinus  may  close  and  a  reaccumulation  of  pus  take  place,  forming  another  ab- 
scess. This  may  be  repeated  several  times  in  the  course  of  a  few  years.  Again, 
in  inflammation  of  the  vulvo-vaginal  gland,  the  duet  may  remain  open  giv- 
ing exit  to  the  pus  as  it  forms  and  constituting  a  sinus  or  discharging  tract. 

The  diagnosis  of  sinus  of  the  vulvo-vaginal  gland  is  made  by  the  history 
of  inflammation  of  the  gland  associated  with  a  sinus  in  that  locality.  By  pal- 
pating the  gland  (Fig.  47),  it  can  often  be  felt  as  a  small  hard  lump,  indicat- 
ing infiltration  and  enlargement.  Pressure  on  this  lump  will  sometimes  cause 
pus  to  flow  from  the  sinus.  A  small  probe  introduced  into  the  sinus  passes  into 
the  region  of  the  gland. 

Treatment.  If  the  sinus  has  a  good-sized  external  opening  and  has  been 
present  only  a  few  weeks,  it  may  close  if  washed  out  daily  with  hydrogen  per- 
oxide. The  peroxide  should  be  forced  to  the  bottom  of  the  sinus  and  it  may 
be  followed  by  iodoform  in  glycerine  (10%,  or  argyrol  (25%)  or  protargol 
(5%  to  10%)  or  silver  nitrate  solution  (2%  to  5%).  In  most  cases,  however, 
the  only  way  to  effect  a  permanent  cure  is  to  extirpate  the  sinus  tract-  and 
the  infiltrated  gland. 

This  is  a  small  operation,  but  the  patient  will  usually  require  a  general 
anesthetic  for  considerable  dissection  is  necessary.  The  parts  are  very  vascu- 
lar and  there  is  much  oozing.  The  resulting  cavity  is  closed  with  sutures. 
The  sutures  serve  also  to  stop  the  bleeding  and  ligatures  are  seldom  necessary. 
Quite  a  depression  is  left  where  the  inflamed  gland  was  situated.  This  depres- 
sion is  not  of  particular  importance  and  in  time  becomes  less  pronounced.  It 
is  well,  however,  to  mention  to  the  patient  before  operation  that  a  small  de- 
pression will  be  left  when  the  inflamed  gland  is  removed. 

When  beginning  the  operation,  in  addition  to  the  usual  antiseptic  meas- 
ures, the  sinus  should  be  washed  out  thoroughly  with  peroxide  and  then  with 
bichloride.  During  the  operation,  care  must  be  exercised  to  avoid  contaminat- 
ing the  cut  surfaces  with  pus  from  the  sinus.  The  object  is  to  remove  all  the 
infected  tissue  and  secure  union  of  the  wound  by  first  intention. 


498  DISEASES    OF    THE   EXTERNAL    GENITALS    AND   VAGINA 

CYST  OF  VULVOVAGINAL  GLAND 

A  cyst  of  the  vulvo-vaginal  gland  is  due  to  an  obstruction  of  the  duct, 
with  a,ccumulation  of  secretion  in  the  gland  causing  it  to  become  dilated.  In 
some  cases  of  inflammation,  gonorrheal  or  otherwise,  cyst  of  the  gland,  instead 
of  abscess,  results.  The  cyst  appears  as  a  fluctuating  swelling  in  the  region 
of  the  gland  (Fig  247). 

The  swelling  is  not  painful  and  the  skin  may  be  moved  freely  over  it. 
The  form  and  location  of  the  swelling  is  like  that  of  abscess,  but  none  of  the 
acute  inflammatory  symptoms  are  present.  Sometimes  the  duct  only  is  the 
seat  of  the  cyst.  In  that  case  the  swelling  is  small  and  is  situated  at  some 
part  of  the  course  of  the  duct. 

The  only  affection  that  is  liable  to  be  confounded  with  this  cyst  is  pu- 
dendal hernia.  The  distinguishing  characteristics  of  hernia  are  marked  in- 
crease of  the  trouble  on  straining,  obstructive  bowel  disturbance,  impulse  in 
the  mass  on  coughing,  tympanitic  percussion  note  over  the  mass  (if  contain- 
ing bowel)  and  the  possibility  of  partial  or  complete  reduction  into  the  peri- 
toneal cavity. 

Treatment.  An  attempt  may  be  made  to  secure  obliteration  of  the  cyst 
without  a  cutting  operation.  Cleanse  the  vaginal  surface  of  the  cyst  and  intro- 
duce the  needle  of  a  small  aspirator  or  a  hypodermic  syringe  and  draw  off  the 
contents  as  completely  as  possible. 

The  labia  minora  and  the  tissues  lying  to  the  outer  and  anterior  part  of 
the  cyst  are  full  of  veins  and  must  be  avoided.  The  bulb  of  the  vestibule 
also,  which  lies  against  the  upper  end  of  the  cyst,  should  be  avoided.  If  the 
needle  is  introduced  through  any  of  these  structures  a  troublesome  hematoma 
may  result;  consequently  all  punctures  of  the  cyst  should  be  made  at  its  in- 
ner and  lower  portion,  just  at  the  margin  of  the  vaginal  mucous  membrane 
where  the  intervening  tissues  are  thin  and  comparatively  free  from  veins. 

After  the  evacuation  of  the  cyst,  a  pad  of  cotton  or  gauze  should  be  ap- 
plied over  it  and  held  firmly  against  it  by  a  T-bandage.  As  soon  as  the  pa- 
tient reaches  home  she  should  go  to  bed  and  remain  there  for  two  or  three 
days,  keeping  the  bandage  applied  firmly.  If  swelling  or  pain  appears,  elevate 
the  hips  on  a  pillow  and  apply  an  ice-bag. 

If  the  cyst  refills,  the  contents  may  again  be  drawn  off  and  some  irritat- 
ing fluid  injected  into  the  cavity  as  in  the  injection  treatment  for  ordinary  hy- 
drocele. 

There  are  two  cutting  methods.  One  method  is  to  open  the  cyst  on  the 
inner  side,  cut  out  some  tissue  on  each  side  of  the  incision,  so  that  it  will  not 
close  so  easily,  euret  the  inner  surface  of  the  sac  and  pack  with  antiseptic 
gauze.  The  external  wound  is  kept  open  until  the  cavity  is  obliterated.  In 
this  method  the  treatment  is  prolonged  and  a  sinus  may  result. 

The  other  method  is  to  extirpate  the  cyst.  In  extirpating  the  cyst,  avoid 
cutting  into  it  if  possible,  as  it  is  much  easier  enucleated  when  distended  than 


CONDYLOMATA    OF    VULVA  499 

■when  collapsed.  The  resulting  cavity  is  closed  with  sutures.  This  method  is  the 
one  of  choice  from  the  very  first  in  all  cases  in  ■which  there  is  no  contraindi- 
cation to  general  anesthesia. 

AVhen  the  patient  is  not  in  good  condition  for  a  general  anesthetic,  the 
cyst  may  in  some  eases  be  extirpated  by  injecting  a  considerable  quantity  of 
a  weak  cocaiiie  solution  (14  to  14% )  or  the  Schleich  solution  No.  2  around 
the  cyst  and  under  it  (infiltration  method).  This  will  do  away  with  the  greater 
part  of  the  pain.  To  facilitate  the  dissection  in  such  cases,  Pozzi  adopted  the 
very  ingenious  plan  of  filling  the  cyst  with  paraf&n.  The  cyst  is  first  punc- 
tured and  the  fluid  dra%\'n  off.  The  cavity  is  then  washed  out  with  hot  water 
and  the  melted  paraffin  is  introduced  at  a  low  temperature.  When  the  cavity 
is  distended,  ice  is  applied  and  in  a  few  minutes  there  is  formed  a  solid  mass, 
Avhich  is  extirpated  under  the  anesthesia  of  the  cold  and  cocaine. 

CONDYLOMATA  OF  VULVA 

Condylomata  are  small  non-malignant  growths  occurring  about  the  vulva. 
There  are  three  varieties. 

1.  The  common  wart,  called  also  ''verruca  vulgaris." 

2.  The  pointed  condyloma,  called  also  "condyloma  acuminatum,"  ''ven- 
ereal wart"  and  "moist  wart." 

3.  The  flat  condyloma,  called  also  "condyloma  latum." 

Etiology,  Pathology,  Sjnnptoms.  The  common  Avart  occurs  rather  fre- 
quently about  the  vulva.  It  is  usually  situated  on  the  labia  majora  or  mons 
veneris.  The  particular  cause  for  it  is  not  known.  It  is  dry  and  sometimes 
much  pigmented,  but  rarely  causes  any  disturbance. 

The  POINTED  C0NDYL0:\IA  or  moist  wart  occurs  on  those  parts  of  the  vulva 
which  are  frequently  moist,  namely,  the  vestibule,  the  vaginal  entrance,  the 
labia  minora,  the  perineum  and  about  the  anus.  In  some  cases  they  occur  on 
the  labia  majora  and  even  on  the  thighs. 

They  are  usually  associated  with  venereal  disease  but  not  necessarily  so. 
They  are  small  pointed  papillary  masses  with  a  thin  covering  of  epithelium 
(Fig.  463).  They  occur  singly  or  in  groups  or  in  large  numbers  (Figs.  240, 
461).  They  may  vary  in  size  from  the  head  of  a  pin  to  a  large  cauliflower 
mass  covering  half  or  more  of  the  vulva  (Figs.  241,  462). 

They  are  due  to  some  irritating  discharge,  usually  gonorrheal.  Sometimes 
they  are  due  to  a  simple  discharge  as,  for  example,  the  increased  vaginal  flow 
of  pregnancy.  When  present  during  pregnancy  they  grow  very  rapidly. 
Whenever  they  are  found,  a  careful  search  should  be  made  for  evidences  of 
previous  gonorrhea. 

Usually  condylomata  are  not  particularly  painful  nor  tender.  In  some 
eases  they  become  inflamed  and  are  then  painful  and  may  bleed  easily.  When 
the  condylomata  are  multiple  and  grouped  together  in  large  masses,  secre- 
tion is  liable  to  lie  in  the  interstices  of  the  growth  and  become  decomposed. 


500 


DISEASES    OF    THE    EXTERNAL    GEXITALS    AXD    VAGIXA 


giving  rise  to  an  offensiA'e  odor  and  considerable  irritation.     If  situated  near 
the  meatus,  considerable  bladder  irritability  may  result. 

The  FLAT  cox'-DTLOMATA  (Figs.  242,  243  j  constitute  the  characteristic  vul- 
var lesions  of  secondary  syphilis.  If  the  overlying  epithelial  layers  are  thro^^ii 
off,  the  flat  condyloma  becomes  a  superficial  ulcer,  a,s  mentioned  under  syph- 
ilis. 


Fig.   461.      Scattered    Cond3-lomata    of   the    \"ulva.      i  Hirst — Diseases   of    Women.') 


Fig.   462.      Condylomata    forming    large    Masses.       ("Pozzi — Treatise    o)i    Gynecology.) 


CONDYLOMATA    OF    Vi:LVA 


501 


Treatment.  The  common  wart  needs  no  treatment  unless  large  or  in 
some  way  troublesome.  In  such  a  ease  it  may  be  removed  the  same  as  warts 
elsewhere,  viz. :  by  injecting  a  few  drops  of  cocaine  solution  beneath  it  and 
then  snipping  it  off  with  the  scissors.  The  base  should  be  touched  with  car- 
bolic acid  or  other  cauterant,  to  check  the  bleeding  and  prevent  return  of  the 
Avart.    If  the  bleeding  is  free,  it  may  be  checked  with  one  or  two  sutures.    If 


Fig.   463.      Cross   section   of   a   Pointed    Condyloma. 


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T^jjg^^^wi|gfr^i'  1  ^ 

j^B^^^g'lP^p 

mBr    'v5'"'^*r^***^^  ^j| 

^^'     "               ^ '              1 

T 

pWPr" 

^ 

- 

>XA 

'-  - 

.^ 

- 

'.JT -"^■'-''-^ 

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, 

^4% 

Fig.   464.     A    Fibroma    of   the    Vagina,      A    portion    of   the   fibroma   is    shown    at   the   lower   part    of 
the    photomicrograph,    and    over    it    lies    the    vaginal    wall    and    thick    stratified    epithelium. 


502  DISEASES    OF    THE    EXTERNAL    GENITALS    AND    VAGINA 

the  patient  objects  to  this  excision  of  the  wart,  the  cannabis  indica  and  sali- 
cylic acid  mixture  may  be  applied.  This  is  to  be  painted  over  the  wart  with 
a  camel's-hair  brush.  It  should  be  applied  freely  morning  and  evening,  the 
hard  crust  over  the  top  of  the  growth  being  occasionally  removed,  that  the 
medicine  may  penetrate  deeper.  This  treatment  continued  for  a  week  or  two 
will  often  cause  the  wart  to  disappear,  but  it  does  not  always  do  so.  This 
treatment  is  rather  tedious  and  uncertain,  but  it  is  not  painful  and  patients 
frequently  prefer  it. 

The  pointed  condylomata  are  treated  as  follows : 

1.  Stop  the  irritating  discharge  which  causes  the  condylomata.  This  re- 
quires an  antiseptic  vaginal  douche,  once,  tvrice  or  thrice  daily,  depending 
on  the  amount  of  discharge.  The  douche  removes  the  discharge  from  the  va- 
gina and  prevents  it  irritating  the  structures  around  the  vaginal  entrance.  In 
addition  to  the  douche,  the  patient  will  probably  require  special  treatment 
as  indicated  by  the  nature  of  the  disease  giving  rise  to  the  discharge. 

2.  Keep  the  condylomata  clean  and  dry.  This  is  accomplished  by  wash- 
ing several  times  daily  with  an  antiseptic  solution,  for  example,  bichloride 
(1  to  2000)  and  then  drying  with  absorbent  cotton  and  dusting  freely  with 
some  drying  powder  such  as  calomel  or  equal  parts  of  bismuth  subnitrate  and 
prepared  chalk  or  equal  parts  of  salicylic  acid  and  calomel.  The  powder  com- 
posed of  tannic  acid,  boric  acid  and  xeroform  does  well,  as  does  also  the  re- 
sorcin  powder.  The  patient  is  given  a  prescription  for  the  required  powder 
and  directed  to  dust  it  on  freely  several  times  daily.  In  the  office  treatment, 
silver  nitrate  stick  or  a  strong  solution  may  be  applied  as  a  cauterant,  or  car- 
bolic acid  may  be  used  as  a  cauterant,  after  anesthetizing  the  growth  by  the 
application  of  cocaine  solution  (20%).  Another  excellent  cauterant  applica- 
tion is  pure  formol,  applied  after  the  use  of  a  cocaine  solution  to  prevent 
pain. 

3.  Excision.  This  is  the  best  plan  to  adopt  when  there  are  only  a  few 
separate  condylomata.  The  growths  are  snipped  off  with  the  scissors  and  the 
base  of  each  touched  with  carbolic  acid  or  liquor  ferri  subsulphatis  to  stop 
the  bleeding.  If  the  base  is  wide  and  considerable  pain  is  anticipated,  a  few 
drops  of  cocaine  solution  (i/^%)  may  be  injected  under  the  growths  before 
excision.  If  there  is  free  bleeding  the  little  wound  may  be  closed  with  a 
suture.  AYhen  a  large  mass  has  formed  (Fig.  259)  with  a  broad  and  vascular 
base,  perhaps  extending  into  the  vagina,  it  is  better  to  give  the  patient  a 
general  anesthetic  and  remove  the  growth  thoroughly  with  the  scissoi^  and 
curet. 

In  PREGNANCY  it  is  Well  to  get  along  if  possible  with  local  cleanliness  and 
drying  powders  and  mild  astringents.  Any  operative  measure,  such  as  exci- 
sion of  the  condylomata  or  cauterizing  them,  may  lead  to  miscarriage.  In 
many  cases  the  simple  measures  above  mentioned  will  effect  a  cure.  But  when 
the   condylomata   are   not    cured  by   the    simple   means,   particularly   if   the 


CYSTS   OF   VAGINA  503 

growth  is  extensive,  the  patient  should  be  anesthetized  and  the  mass  entirely 
removed.  Though  miscarriage  or  premature  labor  may  result  from  such  treat- 
ment, it  is  not  probable  and  with  such  a  case  some  risk  must  be  taken.  If 
large  condylomata,  that  retain  secretion  in  the  crevices,  are  allowed  to  re- 
main until  labor,  they  become  a  source  of  great  danger  to  the  mother  on  ac- 
count of  the  liability  to  puerperal  sepsis.  There  is  danger  to  the  child  also, 
particularly  in  gonorrheal  cases,  because  of  the  liability  to  eye-infection  and 
destructive  ophthalmia. 

The  flat  condylomata  require  the  regular  constitutional  treatment  for 
secondary  syphilis.  Locally,  cleanliness  should  be  secured  by  frequent  wash- 
ing with  a  carbolic  or  other  antiseptic  solution.  If  there  is  much  vaginal  dis- 
charge, antiseptic  vaginal  douches  should  be  given.  Each  time  the  parts  are 
washed,  they  should  be  dried  thoroughly  with  absorbent  cotton  and  dusted 
freely  with  some  drying  powder.  Calomel  makes  an  effective  drying  powder 
in  these  cases. 

If  there  is  troublesome  itching  or  smarting,  the  lesions  may  be  touched 
occasionally  with  silver  nitrate  solution  (10%).  If  an  ulcer  forms,  it  requires 
the  treatment  for  ulcer,  given  elsewhere. 

CYSTS  OF  VULVA 

Occasionally  sebaceous  cysts  occur  on  the  labia  majora  or  the  mons  ve- 
neris. They  present  the  same  characteristics  and  require  the  same  treatment 
as  sebaceous  cysts  elsewhere.  Figs.  259  and  260  show  large  labial  cysts. 
Cysts  of  the  vulvo-vaginal  gland  have  already  been  considered. 

Several  cysts  of  the  labia  minora  have  been  reported  (Fig.  258).  It  is 
generally  supposed  that  they  arise  from  embryologieally  misplaced  glandular 
rests.  If  large  enough  to  be  troublesome  they  are  to  be  excised.  Fig.  261 
shows  a  cyst  of  the  clitoris. 

CYSTS  OF  VAGINA 

Vaginal  cysts  are  rare  and  their  origin  is  not  certain.  Some  are  sup- 
posed to  arise  from  the  remains  of  the  duct  of  Gartner,  but  others  are  found 
in  other  situations.  Vaginal  cysts  vary  in  size  from  the  end  of  the  finger  to 
as  large  as  the  fist  and  even  larger  (Figs.  286,  287).  In  some  cases  the  va- 
ginal wall  is  separate  from  the  cyst  and  moves  freely  over  it,  while  in  other 
cases  the  vaginal  wall  is  closely  adherent  to  the  cyst,  apparently  forming  part 
of  it. 

The  contents  of  the  cyst  may  be  like  serum  or  may  be  milky  or  may  be 
dark  and  thick,  the  color  and  consistency  depending  on  the  amount  of  hemor- 
rhage into  the  cyst  cavity. 

Diagnosis.  The  cyst  differs  from  vaginal  hernia  in  that  it  is  of  gradual 
development  without  apparent  cause,  gives,  on  coughing,  no  impulse  sepa- 


504  DISEASES    OF    THE   EXTERNAL    GENITALS    AND   VAGINA 

rate  from  the  adjacent  vaginal  wall,  can  not  be  reduced  and  is  not  associ- 
ated with  intestinal  disturbance.  The  cyst  differs  from  vaginal  abscess  in 
that  inflammatory  symptoms  are  absent.  In  some  cases,  infection  of  the  cyst 
contents  takes  place  and  the  cyst  becomes  an  abscess.  In  such  cases  it  is 
distinguished  from  a  simple  abscess  by  the  presence  of  a  swelling  long  before 
the  inflammatory  symptoms  developed.  In  some  cases  a  swelling  that  ap- 
pears to  be  a  vaginal  cyst  is  simply  a  pocket  from  the  urethra  (suburethral 
abscess).  Before  subjecting  a  patient  to  operation,  it  is  well  in  a  doubtful 
case,  to  draw  off  a  small  quantity  of  fluid  from  the  supposed  cyst  with  an 
aspirator  that  the  diagnosis  may  be  confirmed. 

Two  other  conditions  that  should  receive  attention  in  the  differential 
diagnosis  of  vaginal  cyst  are,  double  vagina  and  double  ureter.  In  a  case  of 
DOUBiiE  VAGINA  the  sccoiid  vagiua  may  be  completely  shut  off  and  filled  with 
old  menstrual  blood.  It  would  usually  be  somewhat  larger  and  less  tense  than 
the  ordinary  vaginal  cyst,  though  the  latter  is  frequently  of  considerable 
size.  There  would  be  double  uterus  and  the  relation  of  the  mass  to  the  uterus 
would  point  to  one-sided  hemato-colpos.  From  hydro-ureter  or  a  supernu- 
merary ureter,  the  differentiation  would  also  be  rather  difficult  and  depend 
principally  on  the  shape  and  tension  of  the  swelling.  In  a  case  of  double 
ureter,  if  one  ended  blindlj^  alongside  the  vagina  and  became  distended  with 
urine  it  would  form  a  mass  which  would  be  more  sausage-shaped  and  have  less 
tension  than  a  vaginal  cyst.  A  puncture  of  the  mass  with  an  aspirator  needle, 
of  cours-^.  aids  greatlv  in  differentiating  between  these  conditions — the  pres- 
ence of  blood  speaking  for  hemato-colpos,  and  of  urine  for  hydro-ureter. 

Hernia  must  be  carefully  excluded  before  aspirating,  or  fatal  peritonitis 
may  result.  If  it  is  intended  to  remove  the  cyst  by  operation,  only  a  small 
amount  of  fluid  should  be  removed  for  diagnostic  purposes,  for  the  extirpa- 
tion is  more  easily  carried  out  when  the  cyst  is  distended  than  when  col- 
lapsed. 

Treatment.  If  the  cyst  is  large  and  troublesome,  the  most  satisfactory 
way  of  dealing  with  it  is  by  extirpation,  provided  it  is  situated  in  the  lower 
-part  of  the  vagina  where  complete  extirpation  is  practicable.  If  it  is  so  sit- 
uated that  it  can  not  be  completely  extirpated,  remove  a  large  part  of  the  wall, 
curet  the  remaining  portion  and  pack  with  gauze,  and  treat  as  an  abscess 
cavity.  If  the  patient  is  averse  to  operation,  the  cyst  may  be  simply  emptied 
by  aspiration.  There  is  a  possibility  that  it  will  remain  collapsed  for  some 
time  or  even  permanently.  However,  the  probability  is  that  it  will  refill  in 
a  short  time  and  that  extirpation  will  be  necessary. 

If  the  cyst  is  first  discovered  during  pregnancy,  do  not  disturb  it  until 
labor  begins.  When  labor  comes  on  and  the  child's  head  is  beginning  to 
press  into  the  pelvis,  empty  the  cyst  with  an  aspirator,  to  give  room  for  the 
passage  of  the  child.  Do  not  attempt  extirpation  of  the  cyst  nor  incision  and 
drainage,  until  the  patient  has  recovered  from  parturition. 


STASIS    HYPERTROPHY    OF    VULVA  505 

NON-MALIGNANT  TUMORS  OF  VULVA 

Fibrous  tumors  (fibromata)  may  occur  in  the  connective  tissue  of  the 
vulva.  They  are  rare.  When  present  tliey  usually  involve  one  of  the  labia 
majora  (Figs.  256,  257). 

In  some  tumors  there  are  also  bundles  of  muscular  tissue,  evidently  de- 
rived from  the  muscle  fibers  of  the  round  ligament  or  of  the  skin.  Such  tu- 
mors are  of  course  fibromyomata.  Other  tumors  have  a  preponderance  of 
fat  (lipomata),  the  connective  tissue  simply  forming  trabeculae  between  the 
fat  lobules.  Still  other  tumors  contain  myxomatous  tissue,  giving  the  myxo- 
fibromata  and  the  myxo-lipomata.  A  very  rare  form  of  tumor  in  this  region 
is  the  chondroma.  A  few  cases  of  chondroma  of  the  clitoris  have  been  re- 
ported, in  at  least  one  of  which  considerable  ossification  had  taken  place. 

These  non-malignant  tumors  of  the  vulva  may  vary  in  size  from  an  acorn 
to  a  child's  head.  They  present,  in  this  locality,  the  same  symptoms  and  signs 
that  characterize  them  elsewhere.  The  patient  complains  principally  of  the 
weight  of  the  growth  and  of  its  being  in  the  way.  When  large,  they  become 
pedunculated.  On  account  of  the  friction  the  surface  may  become  abraded 
and  infected  and  ulcerated,  adding  greatly  to  the  patient's  distress.  The 
treatment  for  these  growths  is  excision. 

NON-MALIGNANT  TUMOR  OF  VAGINA 

Solid  tumors  (fibrous  and  myomatous)  occasionally  develop  in  the  vag- 
inal wall  (Fig.  464).  Such  a  tumor  may  be  mistaken  for  a  hernia  or  a 
cyst  or  a  malignant  tumor.  Solid  tumors  in  this  situation  are  so  rare  as  to 
require  no  detailed  consideration,  but  the  possibility  of  their  existence  must 
be  kept  in  mind  when  endeavoring  to  determine  the  character  of  the  swelling 
in  this  region. 

When  large  enough  to  cause  trouble,  they  require  the  same  treatment  as 
vaginal  cysts,  i.  e.,  extirpation. 

STASIS  HYPERTROPHY  OF  VULVA 

Stasis  hypertrophy  of  the  external  genitals  is  a  chronic  enlargement  of 
the  same,  due  principally  to  interference  with  the  lymph  circulation.  '^  Ele- 
phantiasis" is  the  term  under  which  most  authors  describe  this  condition,  but 
the  import  given  to  this  word  varies  so  much  that  its  use  leads  to  confusion. 
It  has  been  applied  on  the  one  hand  indiscriminately  to  nearly  all  chronic 
enlargements  of  the  labia  and,  on  the  other  hand,  as  a  special  term  for  the 
designation  of  the  swelling  due  to  the  local  invasion  of  the  lymph  channels 
by  a  parasite  (filaria  sanguinis  hominis).  To  prevent  this  confusion  it  is 
best  to  adopt  another  term,  one  about  which  there  can  be  no  misunderstand- 
ing and  which  indicates  the  most  important  factor  in  the  evolution  of  the 


506  DISEASES   OF    THE   EXTERNAL   GENITALS   AND   VAGINA 

clinical  picture.  The  essential  lesion  is  a  stasis  hypertrophy,  whatever  the 
cause  of  the  stasis  may  be.  As  explained  below  under  etiology,  the  stasis 
may  be  due  to  persistent  ulceration  with  resulting  scar-tissue,  or  to  an  ob- 
structive disturbance  in  the  inguinal  lymph  glands  or  to  local  invasion  of 
lymphatics  by  a  parasite  (filaria).  The  term  ''ulcus  rodens"  given  to  the  con- 
dition by  some  writers,  is  very  good  for  designating  that  peculiarly  persist- 
ent form  of  ulceration  which  is  a  prominent  feature  in  many  of  these  cases, 
but  as  a  term  for  the  whole  clinical  picture  it  is  not  appropriate.  The  hyper- 
trophy may  be  present  without  ulceration  and,  on  the  other  hand,  a  rodent 
ulcer  may  be  present  without  particular  hypertrophy.  Stasis  hypertrophy 
does  not  include  the  following  forms  of  vulvar  enlargement: 

a.  Malformations,  nor  the  condition  known  as  "congenital  elephantiasis," 
which  is  in  reality  a  kind  of  soft  fibroma. 

b.  The  slight  enlargement  of  one  or  both  labia  minora,  without  lymph 
obstruction  and  which  is  supposed  to  be  due  to  frequent  irritation  of  the  struc- 
tures by  masturbation. 

c.  The  enormous  enlargement  of  the  labia  minora  seen  in  some  barbarous 
tribes,  particularly  the  Hottentots  (Fig.  249).  This  is  due  not  to  lymph  sta- 
sis but  to  certain  manipulations  practised  on  the  female  children,  particularly 
stretching  of  the  parts  manually  or  by  weights. 

d.  Fibroma,  lipoma,  hematoma,  carcinoma,  sarcoma,  ordinary  edema, 
acute  inflammatory  enlargement,  hernia. 

e.  The  slighter  degrees  of  enlargement  found  in  the  various  forms  of  vul- 
var ulceration,  namely,  in  the  syphilitic,  tubercular,  malignant  and  rodent  ul- 
cers. In  each  of  these  conditions,  when  present  for  some  time,  there  is  usually 
slight  stasis  hypertrophy,  but  the  disease  giving  rise  to  the  ulceration  is  the 
important  feature  and  hence  the  case  should  be  classed  under  syphilis  or  tu- 
berculosis or  malignant  disease  or  rodent  ulcer.  However,  with  syphilis  or 
rodent  ulcer,  as  the  case  continues  the  hypertrophy  may  in  time  become  the 
most  important  feature  and  then  the  case  could  properly  be  classed  as  one  of 
stasis  hypertrophy.  If  this  fact  of  the  possible  overlapping  of  these  terms 
were  kept  in  mind  and  yet  a  definite  meaning  were  attached  to  each  term 
when  used,  much  confusion  would  be  avoided.  The  term  "elephantiasis" 
should  be  reserved  for  those  cases  of  vulvar  enlargement  in  which  the  enlarge- 
ment becomes  very  great,  i.e.,  of  really  elephantine  proportions  (Fig.  238), 
more  commonly  seen  in  negro  women. 

Etiology.  There  are  thought  to  be  three  causative  factors: 
1.  Chronic  ulceration  about  the  vulva.  This  has  long  been  recognized 
as  an  etiologic  factor  in  the  majority  of  cases.  In  most  cases,  the  ulcera- 
tion spreads  at  one  point  and  heals  at  another,  forming  scar-tissue.  The  con- 
traction of  the  scar-tissue,  and  of  the  inflammatory  infiltration  under  the 
ulcer,  obstructs  the  circulation,  particularly  of  the  lymph,  and  causes  stasis, 
chronic  irritation,  infiltration  and  hypertrophy  of  the  tributary  structures. 
This  same  ulceration  may  lead  to  infection  of  the  lymph  glands  and  the  ob- 


STASIS   HYPERTROPHY   OF    VULVA 


507 


structive    condition   mentioaied    in   the   next   paragraph.      In   Fig.    237,    the 
masses  are  raised  to  show  the  ulceration  beneath. 

2.  Obstructive  changes  in  the  inguinal  lymphatic  glands.  This  factor 
was  brought  out  by  F.  Koch,  and  helps  to  account  for  those  cases  in  which 
there  has  been  no  extensive  ulceration.  The  obstruction  of  the  lymph 
glands  by  disease  of  these  structures  may  be  an  important  factor  also  in  those 
cases  accompanied  by,  and  apparently  due  to,  chronic  ulceration.  The  clos- 
ing of  these  lymph  highways  through  the  glands  may  be  brought  about  by  ex- 
tirpation of  the  glands  or  by  suppuration  of  the  same,  or  even  by  inflamma- 
tory or  degenerative  processes  that  stop  short  of  suppuration,  such,  for  ex- 
ample, as  tertiary  syphilis. 

3.  Local    invasion    of    the    vulvar    lymphatics    by    the    filaria    sanguinis 


A.  B. 

Fig.  465.  Excision  of  External  Genitals.  A.  Showing  enlarged  labia  (stasis  hypertrophy),  with 
the  incision  made  on  the  left  side.  B.  Showing  the  wound  left  when  the  diseased  structures  are  removed. 
The   bleeding  vessels   are  tied      and   the   suturing  is   begun.      (Hirst — Diseases   of    Women.) 


hominis.  This  is  rare  or  unknown  in  this  country,  but  it  occurs  as  an  en- 
demic affection  in  some  countries  (India,  Barbadoes  and  the  Antilles).  Mos- 
quitoes are  thought  to  deposit  the  embryo  beneath  the  epidermis.  There  the 
parasite  multiplies  to  such  an  extent  as  to  choke  the  lymph  channels,  the  ob- 
struction being  due  to  both  the  parasites  proper  and  the  ova. 

Stasis  hypertrophy  is  a  rather  common  affection  among  prostitutes,  in 
whom  the  constant  irritation  from  frequent  coitus  and  from  various  infections 
and  from  lack  of  cleanliness,  tends  to  keep  up  indefinitely  the  chronic  ulcera- 
tion, which  usually  precedes  and  accompanies  the  hypertrophy.  In  this  class, 
chronic  ulceration  is  favored  also  by  the  depressed  general  health  and  in 


508  DISEASES    OF    THE   EXTERNAL    GENITALS   AND   VAGINA 

many  cases  by  tertiary  syphilis  or  the  postsyphilitic  state.  The  postsyph- 
ilitic state  probably  predisposes  to  stasis  hypertrophy  by  producing  poor  tis- 
sue resistance  which  favors  chronic  ulceration,  and  also  by  producing  a 
change  in  the  local  lymph  glands  which  interferes  more  or  less  with  the  flow 
of  lymph  through  them. 

Pathology  and  Symptoms.  There  is  marked  hyperplasia  of  the  skin  and 
subcutaneous  tissues,  and  the  lymph  spaces  are  dilated.  There  is  usually 
considerable  round  cell  infiltration  and  connective  tissue  proliferation.  In 
some  cases  there  is  infection  of  the  lymph  spaces  and  the  formation  of  pockets 
of  pus,  but  this  is  not  a  part  of  the  essential  pathology  of  the  disease.  In 
the  absence  of  infection,  there  are  no  evidences  of  acute  inflammation  in 
ordinary  stasis  hypertrophy. 

The  enlarged  structures  have  about  the  normal  color.  The  skin  may  be 
smooth  (glabrous  variety)  or  rough  and  warty  (verrucous  variety)  with 
marked  exaggeration  of  the  normal  skin  folds.  The  process  may  affect  the 
clitoris  alone  or  one  of  the  labia  alone  or  it  may  affect  all  of  the  structures 
simultaneously  or  in  succession. 

There  is  usually  present  more  or  less  chronic  ulceration.  In  that  variety 
due  to  the  filaria,  the  parasite  and  ova  are  found  choking  the  lymph  spaces 
and  there  are  also  evidences  of  acute  inflammatory  reaction.  The  enlarge- 
ment in  stasis  hypertrophy  may  vary  in  size  from  a  small  thickening,  hardly 
noticeable,  to  a  mass  so  large  as  to  prevent  coitus  and  interfere  with  walk- 
ing (Figs.  232  to  236). 

Examination  reveals  the  enlargement  and  usually  also  the  ulceration 
and  scar-tissue.  In  the  absence  of  infection,  there  are  no  acute  inflamma- 
tory symptoms  and  usually  but  little  congestion. 

The  patients  complain  of  some  discharge  and  itching  about  the  genitals 
and  not  infrequently  symptoms  of  irritation  on  the  part  of  the  bladder  and 
rectum.  What  usually  brings  the  patient  to  the  physician  is  the  discharge 
and  enlargement,  with  resulting  discomfort  and  inconvenience  in  walking  and 
difficulty  in  coitus. 

Diagnosis.  Tertiary  syphilitic  lesions  of  the  vulva  not  infrequently  re- 
semble the  affection  under  consideration,  there  being  present  syphilitic  ulcera- 
tion and  syphilitic  deposit  in  the  tissue.  For  this  reason  a  thorough  course 
of  iodides  is  advisable  in  nearly  all  these  cases  as  a  diagnostic  measure.  In 
some  supposed  cases  of  simple  stasis  hypertrophy,  when  the  patient  is  put 
on  antisyphilitic  treatment,  the  ulcers  heal  rapidly  and  the  swelling  rapidly 
disappears,  showing  that  the  trouble  was  syphilis  and  not  ordinary  stasis  hy- 
pertrophy. However,  the  postsyphilitic  state  undoubtedly  predisposes  to 
chronic  ulceration  with  resulting  stasis  hypertrophy,  and  a  large  number  of 
the  persons  so  afflicted  are  old  syphilitics.  That  it  is  not  syphilis  in  the  ac- 
tive stage,  is  shown  by  the  therapeutic  test — the  iodides  rarely  doing  much 
good. 

From  stasis  hypertrophy  we   must  distinguish   also  tuberculosis   of  the 


PUDENDAL    HERNIA  509 

Tulva  and  malignant  disease,  by  the  special  diagnostic  points  given  under 
each.  To  be  distinguished  also  are  fibroma,  lipoma,  hernia  and  the  enlarge- 
ment of  the  labia  minora  previously  mentioned. 

In  that  rare  form  of  stasis  hypertrophy  due  to  the  filaria,  considerable 
acute  inflammatory  reaction  follows  the  invasion  of  the  lymph  spaces  by  the 
parasite  and  at  this  stage  it  is  very  liable  to  be  mistaken  for  erysipelas  or 
ordinary  cellulitis.  After  these  acute  symptoms  subside  the  brawny  indura- 
tion remains.  Acute  exacerbations  occur  at  irregular  intervals  and  with  each 
exacerbation  there  is  a  decided  increase  in  the  hypertrophy.  If  pus  infection 
of  the  dilated  lymph  spaces  takes  place,  abscesses  and  sinuses  form. 

Treatment.  The  treatment  of  stasis  hypertrophy  is  naturally  divided  into 
two  parts — that  for  the  ulceration  and  skin  irritation,  and  that  for  the  swol- 
len structures. 

The  first  consists  in  cleanliness  and  the  employment  of  the  measures  men- 
tioned under  ulcer  and  under  vulvitis. 

The  second,  i.e.,  treatment  for  the  large  masses,  is  excision.  In  some  of 
the  milder  cases  the  removal  of  the  irritation  and  dermatitis  and  the  treat- 
ment of  the  ulceration,  will  do  away  with  part  of  the  swelling  (the  coincident 
edema)  and  relieve  the  patient  so  much  that  she  is  comfortable.  In  most 
eases,  however,  particularly  where  the  enlargement  is  marked,  the  masses 
should  be  removed.  In  some  cases  the  masses  are  so  much  in  the  way  that 
they  must  be  removed  before  the  ulceration  can  be  satisfactorily  treated. 
But  on  account  of  the  danger  of  infection  the  ulceration  should  be  healed  as 
far  as  possible  and  all  the  dermatitis  removed  before  excision  of  the  mass. 
Infection  is  particularly  dangerous  in  these  cases  on  account  of  the  great 
dilatation  of  the  lymph  spaces,  and  strict  antiseptic  care  must  be  employed  in 
handling  them. 

The  best  way  to  remove  such  a  mass  is  by  clean  excision  Avith  the  knife 
or  scissors  and  closure  of  the  resulting  wound  with  sutures  (Fig.  485).  Bleed- 
ing is  free  and  many  artery  forceps  are  needed  to  catch  the  small  vessels. 
When  there  is  a  large  mass  with  a  broad  pedicle,  it  is  best  to  close  the  wound 
immediately,  a  little  at  a  time  as  the  incision  is  extended  and  the  mass  gradu- 
ally excised.  In  this  way  the  sutures  stop  the  bleeding  at  once,  no  ligatures 
are  necessary  and  comparatively  little  blood  is  lost. 

The  older  method  of  removal  with  the  cautery  leaves  a  broad  surface  to 
heal  by  granulation  and  there  is  much  resulting  scar-tissue  and  distortion. 
Except  in  the  cases  of  very  small  pedicle,  it  is  inferior  to  excision  with  the 
knife.  The  knife  excision  leaves  the  edges  of  the  wound  in  condition  for  ac- 
curate approximation  and  rapid  union  with  a  minimum  amount  of  scar-tissue. 

PUDENDAL  HERNIA 

A  pudendal  hernia  is  a  protrusion  of  the  intestine  or  omentum  or  other 
intraabdominal  structure  into  the  external  genitals.     It  may  take  place  by 


510  DISEASES   OF    THE   EXTERNAL   GENITALS   AND   VAGINA 

way  of  the  inguinal  canal  in  which  case  the  hernia  is  designated  as  "inguino- 
labial"  or  ''superior  labial." 

The  protrusion  may  take  place  by  way  of  the  vagina,  in  which  case  the 
hernia  is  designated  as  ''vaginal,"  "vagino-labial"  or  "inferior  labial." 

Inguino-labial  Hernia.  The  round  ligament  ends  in  the  tissues  at  the 
top  of  the  labium  majus.  In  the  fetus,  the  ligament  is  accompanied  along  the 
inguinal  canal  by  a  prolongation  of  the  peritoneum,  forming  a  small  cavity. 
This  is  usually  obliterated  in  the  full  term  fetus.  In  some  cases,  however,  it 
is  not  obliterated  but  remains  open,  forming  a  small  pocket  or  "canal  of 
Nuck,"  and  along  this  canal  an  inguinal  hernia  may  take  place.  The  hernia 
may  advance  no  further  than  the  inguinal  ring  or,  on  the  other  hand,  it  may 
protrude  more  and  more,  involving  the  upper  part  of  the  labium  majus  and 
later  the  whole  labium  (Fig.  262).  It  corresponds  to  scrotal  hernia  in  the 
male  and  presents  practically  the  same  pathology  and  symptoms.  In  some 
cases  other  structures  than  the  intestine  or  omentum  have  been  found  in  such 
a  hernia-sac,  for  example,  the  ovary.  Fallopian  tube,  uterus  and  even  the 
pregnant  uterus. 

Vagino-labial  Hernia.  In  rare  cases  a  hernial  protrusion  may  take  place 
through  the  pelvic  outlet  by  way  of  the  vagina.  In  such  a  case  the  hernia 
may  descend  in  front  of  the  broad  ligament,  between  the  uterus  and  the  blad- 
der or,  more  rarely,  behind  the  broad  ligament  between  the  uterus  and  the 
rectum.  In  either  case  the  hernial  tumor  appears  first  in  the  vagina  and,  as 
it  grows  larger  approaches  the  vaginal  opening  and  distends  the  lower  part 
of  one  labium  (Fig.  263).  In  this  situation  it  produces  an  appearance  some- 
what resembling  a  vulvo-vaginal  cyst,  for  which  it  may  be  mistaken. 

Diagnosis.  Hernia  differs  from  other  swellings  in  this  region,  for  ex- 
ample, hematoma,  cyst,  fibroma,  stasis  hypertrophy,  cellulitis,  in  the  follow- 
ing particlilars :  ' 

Impulse  on  Coughing.  This  sign,  however,  may  be  absent  if  strangula- 
tion has  taken  place. 

Resonance  on  Percussion.  This  sign  is  present  only  if  the  mass  contains 
intestine.    It  is  not  found  with  omentum  or  ovary  or  tube. 

Mat  be  reduced  into  abdominal  CA\^TY.  This,  of  course,  is  possible 
only  in  reducible  hernia.  If  the  supposed  hernia  can  not  be  reduced  with  the 
patient  in  the  dorsal  position,  she  may  be  placed  in  the  knee-chest  posture  and 
the  reduction  again  attempted.  This  is  especially  effective  in  the  vaginal  form 
of  hernia. 

Intestinal  Obstruction.  Usually  there  is  not  enough  obstruction  to  pro- 
duce serious  symptoms  nor  interfere  with  the  passage  of  the  intestinal  con- 
tents, but  when  evidence  of  such  obstruction  does  occur  it  is  a  very  important 
diagnostic  symptom. 

History.  Hernia  usually  appears  in  conjunction  with  some  straining  effort. 
Hematoma  of  the  vulva  is  usually  due  to  some  external  injury.  Cellulitis  fol- 
lows a  wound  or  ulcer.     Stasis  hypertrophy  is  preceded  by  chronic  ulceration 


PUDENDAL    HYDROCELE  511 

and  scar-tissue  formation.  The  other  swellings  of  this  locality  (cyst,  tumor) 
develop  gradually  and  without  apparent  cause. 

Treatment.  The  treatment  for  hernia  in  this  situation  is  the  same  as  for 
hernia  elsewhere,  namely,  reduction  and  retention  of  the  replaced  viscera 
-vvithin  the  abdominal  cavity,  if  that  can  be  satisfactorily  accomplished.  An 
iNGurisro-LABiAL  hernia  can  frequently  be  retained  wath  the  ordinary  hernia 
truss.  If  the  reduction  can  not  be  accomplished  or  if  satisfactory  retention 
can  not  be  secured,  then  the  operation  for  the  radical  cure  of  the  hernia  is 
indicated. 

In  the  form  of  pudendal  hernia  in  which  the  protrusion  takes  place  by  way 
of  the  pehac  outlet  and  vagina  (vagino-labl4.l),  there  is  seldom  enough  obstruc- 
tion at  the  hernial  opening  to  produce  troublesome  symjjtoms.  When  the  pa- 
tient is  placed  in  the  knee-chest  posture,  the  protruding  mass  returns  within 
the  abdominal  cavity  and  in  some  cases  satisfactory  retention  may  be  secured 
by  means  of  a  pessary  that  puts  the  vaginal  walls  on  the  stretch  or  that  plugs 
the  vaginal  canal.  Various  forms  of  pessary  may  be  tried  until  an  effective 
one  for  that  particular  case  is  found.  In  some  cases  the  uterine  supporter, 
consisting  of  an  abdominal  belt  and  vaginal  stem  supporting  a  hard  rubber 
cup  or  ball  (Fig.  438),  is  the  most  satisfactory  form  for  the  vaginal  hernia. 

Where  only  temporary  retention  is  needed,  as  at  the  beginning  of  labor, 
the  vagina  may  be  packed  with  gauze  or  cotton  and  the  patient  kept  in  bed 
and  if  necessary  in  Sims'  posture,  or  in  the  dorsal  posture  with  hip  elevated 
on  pillows.  If  the  hernia  still  persists  in  coming  down  the  patient  may  be 
propped  up  for  a  time  in  a  modified  knee-chest  posture,  care  being  taken  that 
the  abdomen  is  free  from  constriction  or  pressure,  so  that  the  intestines  may 
fall  to  the  upper  part  of  the  abdominal  cavity.  A  vaginal  hernia  associated 
with  pregnancy  and  labor  makes  a  serious  complication  and  requires  careful 
handling,  for  there  is  ahvays  the  danger  that  the  hernia  may  be  caught  and 
held  in  front  of  the  advancing  head,  with  fatal  results. 

A  vaginal  hernia  causing  serious  symptoms,  which  can  not  be  relieved  by 
other  measures,  requires  operation  for  the  permanent  closing  of  the  hernial 
opening.  In  a  case  in  wdiich  the  hernial  opening  can  be  satisfactorily  reached 
for  operative  closures  by  way  of  the  vagina,  that  route  for  the  operation 
should  be  chosen  as  it  is  less  dangerous. 

In  other  cases  abdominal  section  is  indicated. 

PUDENDAL  HYDROCELE 

In  some  patients,  a  canal  persists  along  the  round  ligament,  the  internal 
end  of  the  canal  being  closed.  If  a  collection  of  fluid  takes  place  in  the  sac 
thus  formed,  the  result  is  a  pudendal  hydrocele,  corresponding  to  hydrocele 
of  the  cord  in  the  male.  It  is  called  also  "labial  hydrocele"  and  occupies  the 
same  location  as  an  inguinal  hernia. 

It  differs  from  hernia  in  that  it  is  dull  on  percussion,  can  not  be  reduced, 


512  DISEASES    OF    THE    EXTERNAL    GENITALS    AND   VAGINA 

gives  little  or  no  impulse  on  coughing,  is  not  associated  with,  evidences  of  in- 
testinal obstruction  and  has  developed  gradually  without  apparent  cause. 
Great  care  is  necessary  in  diagnosticating  this  rare  affection,  for  it  would  be 
fatal  to  mistake  hernia  for  hydrocele  and  treat  it  by  injection.  It  must  be 
differentiated  also  from  cystic  adenomyoma  of  the  round  ligament.  Several 
such  case«  have  been  reported.  In  hydrocele,  the  cyst  wall  would  be  thinner 
than  in  the  cystic  adenomyoma,  though  in  some  of  the  cases  the  adenomyoma 
can  only  be  distinguished  microscopically.  Pudendal  hydrocele  must  be  differ- 
entiated also  from  hernia  of  the  ovary  with  cystic  degeneration. 

Treatment.  If  the  collection  of  fluid  is  small  and  causes  no  inconven- 
ience, leave  it  alone  or  have  the  patient  rub  in  some  ointment,  such  as  oleate 
of  mercury,  once  daily  with  gentle  massage.  If  the  swelling  causes  trouble, 
the  fluid  may  be  drawn  off  and  an  irritating  injection  made,  the  same  as  for 
treatment  of  ordinary  hydrocele  in  the  male.  Before  employing  this  treat- 
ment it  must  be  determined  positively  that  the  cavity  of  the  sac  is  shut  off 
from  the  peritoneal  cavity. 

A  safer  and  more  certain  plan  of  treatment  is  to  extirpate  the  sac,  or  a 
large  part  of  it,  and  close  the  wound  by  sutures. 

HEMATOMA  OF  VULVA 

A  hematoma  is  a  collection  of  blood  in  the  tissues.  The  genitals  are  very 
vascular  and  also  present  much  loose  subcutaneous  tissue  into  which  hemor- 
rhage may  take  place  with  Init  little  resistance  until  a  large  mass  is  formed 
(Fig.  230). 

Pregnancy,  pelvic  tumors  and  other  conditions  that  increase  the  vascu- 
larity of  the  parts,  predispose  to  hematoma.  The  exciting  cause  is  an  injury 
that  starts  subcutaneous  bleeding.  A  severe  injury  caused  by  a  fall  astride 
some  object  is  very  liable  to  cause  hematoma.  The  bruising  of  the  tissues  by 
the  child's  head  in  labor  or  by  the  obstetric  forceps  may  cause  hematoma.  A 
slight  subcutaneous  surgical  procedure  about  the  genitals,  such  as  puncture 
of  a  cyst  with  a  hypodermic  needle,  may  be  followed  by  a  hematoma.  For 
this  reason  it  is  important  in  puncturing  a  cyst  of  the  vulvo-vaginal  gland  to 
make  the  puncture  on  the  inner  side  where  the  intervening  layer  of  tissue  is 
thin  and  comparatively  free  from  veins.  During  pregnancy  the  veins  of  the 
external  genitals  become  enlarged  and  varicose  and  sometimes  there  is  a 
spontaneous  rupture  of  a  vein  subcutaneously,  giving  rise  to  a  hematoma 
without  external  injury. 

Symptoms  and  Diagnosis.  After  some  slight  injury,  a  swelling  is  noticed, 
which  increases  rapidly  in  size  and  is  accompanied  by  considerable  pain, 
especially  when  the  patient  is  standing.  If  large,  the  SAvelling  distorts  the 
parts  very  much,  in  some  cases  so  much  that  the  individual  structures  are 
identified  with  difficulty.  The  swelling  presents  induration  and,  if  a  large 
collection  of  blood  has  formed,  there  may  be  fluctuation. 


HEMATOMA    OF    VULVA  513 

The  swelling  and  pain  and  induration  are  much,  the  same  as  in  acute  cel- 
lulitis and  it  may  be  mistaken  for  that  affection,  particularly  if  the  hemor- 
rhage is  situated  so  deeply  that  the  skin  is  not  discolored.  In  one  typical  case, 
which  the  author  saw  in  consultation,  the  physician  was  much  alarmed,  fear- 
ing that  he  had  caused  a  serious  infection.  He  had  punctured  a  small  cyst 
with  a  hypodermic  syringe  and  drawn  off  the  fluid.  Within  twenty-four  hours 
a  large  swelling  gradually  formed  accompanied  by  much  pain  and  distending 
and  distorting  the  genitals  on  that  side.  In  the  next  twenty-four  hours  the 
swelling  seemed  to  get  worse  instead  of  better.  He  decided  it  would  be 
necessary  to  make  deep  incisions  to  stop  the  serious  spreading  infection. 
The  findings  on  examination  together  with  the  history,  showed  that  the 
trouble  was  a  hematoma  following  the  hypodermic-needle  puncture.  Rest 
A^dth  the  hips  elevated  and  an  ice  bag  applied  locally  was  the  treatment 
adopted,  with  satisfactory  result. 

The  differential  diagnostic  points  between  hematoma  and  cellulitis  are 
that  the  hematoma  begins  to  develop  within  a  few  hours  after  the  injury,  too 
soon  for  infection  to  develop,  and  that  there  is  little  or  no  fever  and  that  the 
tenderness  on  superficial  palpation  and  the  local  heat  are  neither  so  marked 
as  in  acute  infiammation.  In  a  few  days  the  extravasated  blood  finds  its  way 
to  near  the  surface  and  colors  the  skin  and  confirms  the  diagnosis. 

Treatment.  Put  the  patient  to  bed  and  elevate  the  hips  by  placing  a 
pillow  under  them,  at  the  same  time  arranging  a  pillow  under  the  knees  so 
that  the  patient  will  be  comfortable,  and  apply  an  ice  bag  over  the  swelling. 
The  patient  should  be  kept  perfectly  quiet  in  this  position  until  the  hemor- 
rhage ceases — several  hours  if  necessary.  If  there  is  much  pain,  sedatives 
should  be  given  to  keep  the  patient  quiet.  The  cessation  of  the  hemorrhage 
is  indicated  by  the  swelling  ceasing  to  increase  in  size  and  by  diminution  in 
the  pain. 

If  the  hematoma  is  very  large  and  increasing  in  size,  it  is  advisable  to 
incise  the  swelling,  under  antiseptic  precautions,  turn  out  the  clots,  ligate  the 
bleeding  vessel,  or  vessels,  cleanse  the  cavity  and  obliterate  it  with  sutures. 
This  avoids  sloughing  of  the  skin,  suppuration  of  the  blood  collection  and  dan- 
gerous septicemia.  In  the  later  treatment  of  a  case  in  Avhich  the  incision 
has  not  been  necessary,  the  patient  must  be  kept  in  bed  until  absorption  is 
well  under  way.  If  suppuration  takes  place  in  the  collection  of  blood  the 
resulting  abscess  must  be  opened. 

A  large  hematoma,  especially  if  occurring  in  labor  or  advanced  pregnancy, 
is  a  serious  matter.  The  swelling  may  burst  and  fatal  external  hemorrhage 
occur  or  the  patient  may  bleed  to  death  without  external  opening,  the  blood 
simply  burrowing  in  the  loose  subcutaneous  tissues.  Such  a  serious  result  is 
rare,  but  the  fact  that  it  may  occur  must  be  kept  in  mind  and,  if  the  hemor- 
rhage persists  in  spite  of  the  ordinary  measures,  the  affection  should  be 
treated  by  operation  before  the  patient  is  too  weak.  After  the  blood  clots 
are  turned  out,  an  attempt  should  be  made  to  catch  the  bleeding  vessels  with 


514 


DISEASES   OF    THE   EXTERNAL   GENITALS   AND   VAGINA 


forceps.  If  the  particular  vessel  that  is  bleeding  can  not  be  located,  catch 
the  bleeding  tissues  rapidly  with  forceps  until  the  hemorrhage  is  stopped 
and  then  ligate  the  bleeding  areas  en  masse  or  include  them  in  sutures. 

It  has  been  recommended  in  these  cases  to  stop  the  hemorrhage  by  firm 
packing,  but  valuable  time  may  be  lost  in  placing  a  packing  which,  after 
all,  may  fail  to  stop  the  bleeding.  The  safer  plan  in  severe  cases  is  to  catch 
the  bleeding  vessels  and  ligate  them,  so  that  there  is  no  chance  for  further 
loss  of  blood. 

VARICOSE  VEINS  OF  VULVA 

The  veins  about  the  external  genitals  may  become  markedly  varicose, 
the  irregular  dilatation  being  due  to  some  obstruction  to  the  pelvic  circula- 
tion, such  as  pregnancy  or  a  pelvic  tumor.  The  dilatation  of  the  veins  only 
rarely  gives  rise  to  troublesome  symptoms.    Sometimes  the  patient  complains 


Fig.  466.  Excision  of  Varicose  Veins  of  Vulva.  A.  The  veins  have  been  exposed  by  incision 
through  the  skin,  and  the  ligatures  are  being  passed.  B.  The  ligatures  have  been  tied,  the  varicose  veins 
excised  and  the  pedicles  brought  together.  The  operation  is  completed  by  a  continuous  suture  closing 
the    skin   incision.      (Ashton — Practice    of    Gynecology.) 

of  itching  or  of  tension  in  the  parts.  Sometimes  she  becomes  alarmed  on  ac- 
count of  the  enlargement  and  consults  the  physician  simply  to  know  the 
cause.  Occasionally,  however,  there  may  be  marked  enlargement  (Fig.  239) 
with  achmg  in  the  parts  and  much  irritation  of  the  skin.  The  danger  in 
these  cases  is  that  a  severe  hemorrhage  may  take  place,  or  a  large  hematoma  • 
form  from  slight  injury  or  from  spontaneous  rupture  of  a  varicose  vein. 

Treatment.  Usually  no  treatment  is  required  beyond  directing  the  pa- 
tient to  keep  the  bowels  well  open  and  to  avoid  lifting  or  straining  as  much 


INJURIES   OF   EXTERNAL   GENITALS  515 

as  possible.  Anything  that  increases  the  intrapelvic  pressure  or  interferes 
with  the  pelvic  circulation  tends  to  increase  the  venous  dilatation.  In  ad- 
vanced pregnancy,  an  abdominal  supporter  takes  some  of  the  weight  of  the 
uterus  from  the  anterior  part  of  the  pelvis  and  in  that  way  may  improve  the 
circulation  there.  If  the  dilatation  is  sufficient  to  give  the  patient  trouble, 
some  relief  may  be  afforded  by  a  pad  and  T-bandage,  so  applied  as  to  sup- 
port the  veins  and  prevent  further  dilatation.  The  patient  should  take  the 
recumbent  posture  several  times  daily,  and  in  some  cases  it  may  be  advisable 
to  keep  her  in  bed  continuously  in  the  later  weeks  of  pregnancy. 

If  there  should  be  subcutaneous  rupture  of  a  vein,  employ  the  treatment 
given  under  hematoma. 

If  there  should  be  external  rupture,  employ  the  treatment  given  below  for 
open  hemorrhage  following  injury. 

When  in  the  non-pregnant,  the  veins  are  so  much  enlarged  that  they  are 
troublesome,  they  may  be  excised.  They  are  exposed  by  an  incision  through 
skin  covering  them  (Fig.  466-A),  ligated  at  each  end  and  excised  (Fig.  466-B) 
and  the  stumps  brought  together  and  the  incision  closed  by  sutures. 

INJURIES  OF  EXTERNAL  GENITALS 

The  genitals  are  in  such  a  well-protected  situation  that  injuries  are  rare. 
Such  injuries  as  do  occur,  apart  from  labor,  are  due  usually  to  a  fall  astride 
some  object  or  to  kicks  and  blows  intentionally  inflicted  or  to  injuries  in 
coitus. 

Injuries  in  this  locality  should  be  treated  on  the  same  general  principles 
that  govern  the  treatment  of  injuries  in  other  localities,  viz.,  stop  hemor- 
rhage, secure  asepsis  as  far  as  possible,  approximate  divided  tissues  sufficiently 
to  restore  function  and  afterward  protect  the  wound  with  a  suitable  dressing. 

There  are  two  special  characteristics  of  injuries  in  this  locality  that  must 
be  kept  in  mind. 

1.  Free  Hemorrhage.  The  parts  are  very  rich  in  blood  vessels,  particu- 
larly veins,  and  slight  injury  may  cause  severe  bleeding,  either  as  external 
hemorrhage  from  an  open  wound  or  as  subcutaneous  hemorrhage  from  a 
bruise,  giving  rise  to  a  hematoma. 

An  instance  of  troublesome  hemorrhage  from  a  slight  injury  is  the  per- 
sistent bleeding  that  occasionally  follows  the  small  tear  of  the  hymen  in  the 
first  coitus.  On  account  of  modesty  and  embarrassment,  the  newly  married 
couple  hesitate  to  call  in  assistance,  and  sometimes  the  bleeding  persists  for 
hours — until  they  do  finally  call  a  physician,  who  may  find  the  bedding  soaked 
with  blood  and  the  bride  almost  exsanguinated. 

Open  hemorrhage  from  injury  to  genitals  should  be  stopped  by  packing 
or  by.  sutures  or  by  forceps  or  by  ligature  of  separate  vessels  or  by  ligature  of 
the  bleeding  tissue  en  masse  as  indicated  by  the  nature  of  the  wound.     After 


516  DISEASES   OF    THE   EXTERNAL   GENITALS   AND   VAGINA 

treatment  of  the  wound,  the  patient  should  be  kept  in  bed  with  hips  elevated 
until  all  tendency  to  hemorrhage  is  past.  In  attempting  to  stop  hemorrhage, 
either  from  a  wound  or  during  an  operation,  if  the  bleeding  vessels  cannot 
be  made  out  and  the  bleeding  is  free,  the  most  satisfactory  plan  is  to  pass  one 
or  more  sutures  through  the  bleeding  area  and  tie  them. 

In  case  of  injury  about  the  venous  masses  called  the  bulbs  of  the  vesti- 
bule, the  hemorrhage,  whether  open  or  subcutaneous,  may  often  be  con- 
trolled by  packing  the  vagina  firmly  and  then  putting  a  firm  compress  over 
the  vulva,  such  as  a  folded  towel  held  in  place  by  a  strong  T-bandage  making 
firm  pressure. 

In  open  hemorrhage  from  a  small  wound,  if  the  pressure  does  not  con- 
trol it,  the  wound  may  be  packed  with  pledgets  of  cotton  dipped  in  liquor 
ferri  subsulphatis  or  in  tannic  acid  powder,  and  then  the  vaginal  packing  and 
vulvar  compress  employed. 

In  SUBCUTANEOUS  HEMORRHAGE  (hematoma)  the  patient  should  receive  the 
treatment  described  elsewhere  for  that  affection. 

2.  Marked  Swelling'.  In  this  locality  the  subcutaneous  tissues  are  loose 
and  decided  swelling  is  liable  to  follow  an  injury,  either  immediately  from 
subcutaneous  hemorrhage   or  serous   effusion    or    later    from    inflammatory 

exudate. 

To  prevent  the  swelling,  or  diminish  it  if  present,  put  the  patient  to  bed, 
elevate  the  hips  and  apply  an  ice  bag  over  the  parts.  If  the  swelling  is  from 
inflammation,  hot  applications  may  give  more  relief  than  the  cold. 

For  further  treatment  of  vulvar  swelling  see  hematoma  and  also  cellulitis 
of  vulva. 

KRAUROSIS  VULVAE 

Kraurosis  vulva  is  a  term  applied  to  a  rather  rare  affection  of  the  ex- 
ternal genitals  characterized  by  atrophy  and  shrinking  of  the  skin  and  oblit- 
eration of  the  normal  folds,  and  a  change  in  the  consistency  of  the  epidermis 
by  which  it  becomes  somewhat  like  scar-tissue.  It  is  known  also  as  "atrophy 
of  the  vulva,"  and  as  "progressive  cutaneous  atrophy." 

The  essential  cause  is  not  known.  It  has,  in  various  cases,  been  preceded 
by  eczema  and  other  chronic  inflammatory  diseases  of  the  vulva,  by  pruritus 
vulvae,  giving  rise  to  much  scratching  and  irritation  and  excoriation,  by  re- 
moval of  the  uterine  appendages  and  by  chronic  vaginal  discharge.  It  has, 
to  some  extent,  been  attributed  to  each  of  these  conditions,  but  apparently 
none  of  them  constitute  the  essential  factor  in  its  development. 

Age  seems  to  be  a  definite  factor  in  the  etiology,  for  it  occurs  almost  ex- 
clusively in  women  near  or  past  the  menopause.  This  would  seem  to  indi- 
cate that  it  is  in  some  way  connected  with  senile  atrophic  changes.  As  cu- 
taneous atrophy  is  such  a  marked .  feature  of  the  affection,  it  has  been  sur- 
mised that  it  is  due  to  an  atrophic  affection  of  the  nerves  of  the  parts,  and 


KRAUROSIS   VULVAE  517 

marked  changes  in  the  nerves  have  been  demonstrated.     But  whether  such 
changes  are  primary  or  secondary  is  somewhat  uncertain. 

Pathology  and  Symptoms.  In  the  beginning  there  is  a  low-grade  inflam- 
matory process,  which  appears  in  spots  just  outside  the  vaginal  opemng  or 
on  the  labia.  The  spots  are  hyperemic  (reddened)  and  may  be  slightly  swol- 
len but  are  usually  depressed.  In  the  beginning,  hypertrophic  areas  are  some- 
times noticed.  The  spots  are  painful  on  pressure  and  for  that  reason  sexual 
intercourse,  or  even  the  introduction  of  a  douche  nozzle,  may  be  very  painful. 
As  the  disease  progresses,  the  older  portions  lose  their  color  and  elasticity. 
The  hyperemia  disappears  and,  instead,  the  tissue  becomes  white  and  dry 
and  brittle  and  cracks  easily  (Fig.  200). 

Another  marked  characteristic  is  the  tendency  to  shrink.  The  atrophic 
contraction  may  progress  to  such  an  extent  that  the  vaginal  opening  is  much 
narrowed  (Fig.  200).  Microscopic  examination  of  the  excised  tissue  shows 
that  the  process  is  essentially  a  chronic  inflammatory  atrophy  or  cirrhosis  of 
the  skin.  In  the  ncAV  areas,  there  is  serous  and  cellular  exudate,  with  hyper- 
emia and  occasionally  slight  hemorrhage.  In  this  stage  there  may  be  decided 
thickening  of  the  affected  spots.  Later,  the  cellular  exudate  becomes  organ- 
ized, with  resulting  contraction  and  hardening  and  atrophy.  The  glandular 
structures  (sweat  glands,  sebaceous  glands  and  hair  follicles)  are  slowly  ob- 
literated by  pressure-atrophy,  and  there  is  left  simply  cirrhotic  tissue. 

The  pathologic  changes  just  described  are  usually  accompanied  by 
burning  and  itching  and  tenderness.  Owing  to  the  sensitive  spots  and  the 
narrowing  of  the  vaginal  orifice,  coitus  may  be  painful  or  impossible.  Owing 
to  the  brittleness  of  the  tissues,  the  examination  may  cause  fissures,  which  add 
to  the  patient's  discomfort.  This  affection  is  one  of  the  causes  of  persistent 
and  severe  pruritus  Aailvae. 

In  some  cases,  but  little  discomfort  seems  to  result  from  the  pathologic 
changes.  The  disease  is  gradually  progressive  for  a  number  of  years  but  is 
not  self-limited  and  spontaneous  cure  can  not  be  promised,  though  in  the  areas 
in  which  the  skin  structures  are  practically  destroyed,  the  pain  and  itching 
may  be  much  diminished. 

Treatment.  Temporary  relief  may  be  afforded  by  the  measures  given 
under  Pruritus  Vulvae.  One  case  was  much  benefited,  in  fact  temporarily 
cured,  by  the  use  of  the  sharp  curet  followed  by  the  long  continued  applica- 
tion of  a  3%  solution  of  salicylic  acid  in  alcohol. 

One  writer  recommends  that  an  ointment  containing  one  to  three  per  cent 
of  yellow  oxide  of  mercury,  be  rubbed  well  into  the  parts  by  the  patient  twice 
daily,  and  that  twice  weekly  the  physician  introduce  the  speculum,  cleanse 
the  vulva  and  vagina  with  a  spray  of  hydrogen  peroxide  and  then  apply  the 
above  ointment  to  all  the  affected  surfaces. 

In  these  cases,  the  X-ray  treatment,  administered  by  a  competent  person, 


518  DISEASES   OF   THE   EXTERNAL   GENITALS   AND   VAGINA 

sometimes  gives  great  relief  after  other  measures  have  failed,  and  if  continued 
may  effect  a  cure. 

The  justifiable  assumption  that  the  atrophic  changes  in  the  vulvar  skin 
are  the  result  of  cessation  of  ovarian  function  of  late  has  led  to  the  use  of 
ovarian  extracts  in  the  treatment  of  kraurosis.  The  results  are  uncertain, 
but  most  satisfactory,  at  least  in  some  cases  (see  Chapter  xv). 

Permanent  relief  in  many  cases  may  be  afforded  by  extirpation  of  the 
involved  tissue,  and  this  operation  should  be  carried  out  when  the  symptoms 
are  severe  and  not  relieved  by  other  measures.  Excision  of  the  affected  tis- 
sue should  not,  however,  be  carried  out  until  the  disease  has  existed  some  time 
and  its  probable  limits  can  be  defined.  If  in  the  early  stage  the  parts  then 
affected  are  excised,  there  is  strong  probability  of  the  development  of  the 
same  process  in  remaining  tissues,  necessitating  a  second  operation.  "When 
an  operation  is  decided  upon,  the  incision  should  include  all  the  superficial 
areas  involved  and  should  be  deep  enough  to  include  part  of  the  subcutaneous 
tissue. 

The  resulting  wound  should  be  closed  as  far  as  possible  by  sutures  (Fig. 
465-B).  "When  the  margins  of  the  wound  can  not  be  brought  together,  the 
uncovered  portion,  if  small,  may  be  left  to  granulate.  If  the  uncovered  por- 
tion is  large,  immediate  skin-grafting  may  be  done  at  the  time  of  the  operation. 

The  results  of  extirpation  are  encouraging.  Decided  relief  is  afforded 
arid  in  some  cases  there  is  a  complete  cure.  Some  of  the  skin  surface,  unaf- 
fected at  the  time  of  the  operation,  may  show  evidences  of  the  disease  later, 
with  symptoms  requiring  treatment.  If  the  symptoms  are  severe  and  per- 
sistent, those  portions  of  skin  may  also  be  excised.  This  may  not,  however,  be 
necessary  and  other  methods  for  relieving  the  pruritus  should  be  given  a 
thbrough  trial. 

PRURITUS  VULVAE 

Pruritus  vulvae  signifies  simply  itching  about  the  external  genitals,  but 
by  common  usage  the  term  has  come  to  be  restricted  to  those  cases  in  which 
the  itching  and  burning  is  marked  and  persistent. 

Etiology  and  Pathology.  The  general  nervous  disturbances  and  the  local 
atrophic  changes  that  accompany  and  follow  the  menopause,  predispose  to 
pruritis  vulvae,  hence  the  vast  majority  of  cases  are  found  in  that  period  of 
life. 

The  following  are  the  exciting  causes : 

1.  An  Irritating  Vaginal  Discharge.  The  discharge  may  originate  in  the 
vagina  or  in  the  uterus.  Adhesive  vaginitis,  which  occurs  principally  in  the 
aged,  is  a  frequent  cause  of  pruritus  vulvae.  Sometimes  a  discharge  which  is 
so  slight  as  not  to  be  noticed  by  the  patient,  will  keep  up  a  troublesome 
pruritus,  the  pruritus  disappearing  temporarily  when  the  discharge  is  kept 


PRURITUS   VULVAE  519 

from  irritating  the  external  genitals  by  the  administration  of  douches  or  by  a 
tampon  against  the  cervix. 

2.  Irritating  Urine,  for  example  diabetic  urine,  highly  acid  urine  and  pus- 
bearing  urine  due  to  inflammation  of  the  bladder  or  kidney. 

3.  Parasitic  Affections,  of  which  the  most  common  in  this  region  is  pedicu- 
losis pubis.  In  children  thread-worms  from  the  rectum  may  cause  persistent 
itching. 

4.  Skin  Diseases,  such  as  eczema,  follicular  inflammation  and  prurigo. 

5.  Lack  of  Cleanliness. 

6.  Growth  of  short  bristly  hairs  on  the  inner  surface  of  the  labia.  These 
scratch  and  irritate  the  adjacent  surface  and  sometimes  cause  very  troublesome 
pruritus.  Occasionally  such  irritation  is  caused  by  the  short  hairs  present  for 
some  weeks  after  shaving  the  parts  for  an  operation. 

7.  Friction  from  exercise,  especially  in  very  stout  persons. 

8.  Kraurosis  Vulvae,  or  as  it  is  sometimes  called  "local  nerve  fibrosis." 
J.  C.  "Webster  carefully  studied  the  microscopic  characteristics  of  excised  tis- 
sue in  several  cases  of  pruritus  vulvae,  and  found  a  progressive  nerve  fibrosis, 
affecting  principally  the  nerves  of  the  clitoris  and  labia  minora.  It  affected 
both  the  nerves  proper  and  the  nerve  endings.  It  was  apparently  distinct 
from  the  cellular  infiltration  of  the  subepithelial  tissues  caused  by  scratching. 

9.  Chronic  Congestion,  from  diseases  of  the  uterus  or  tubes  or  ovaries  or 
other  pelvic  structures. 

10.  Functional  Nervous  Disturbances.  In  some  cases,  no  cause  for  the 
disturbance  can  be  found  and  apparently  no  local  changes  are  present,  aside 
from  the  abrasions  and  irritation  caused  by  the  scratching.  Under  such  cir- 
cumstances the  disease  is  classed  as  a  ''neurosis." 

In  some  cases  the  gouty  diathesis  is  apparently  responsible  for  the  trouble. 
The  presence  in  the  blood  of  urea,  sugar,  bile,  or  other  products  of  faulty 
metabolism  have  a  general  irritating  effect  on  the  vulvar  and  vaginal  sur- 
faces. Alcoholic  drinks,  rich  foods  and,  in  certain  persons,  fish  or  shell-fish, 
may  assist  in  causing  the  disease. 

Symptoms.  The  patient  complains  of  an  intense  itching  about  the  geni- 
tals. It  may  be  confined  to  the  clitoris,  labia  or  vestibule,  or  it  may  involve 
all  these  structures  and  also  adjacent  regions,  for  example,  the  vagina,  anus 
and  inner  sides  of  the  thighs.  The  itching  and  burning  may  be  practically 
continuous,  but  more  often  it  is  intermittent  in  character.  It  may  disappear 
spontaneously  for  several  hours  or  days  or  even  longer,  only  to  return  as  sud- 
denly as  it  disappeared.  Congestion  at  the  menstrual  period  or  during  preg- 
nancy increases  the  pruritus.  Irritating  articles  of  food  and  also  alcoholics 
often  have  the  same  effect.  The  warmth  of  the  bed  usually  makes  the  itch- 
ing worse,  consequently  the  patient  may  lose  much  sleep.  During  sexual  inter- 
course the  itching  and  burning  are  much  increased. 

Frequently  the  distressing  symptoms  persist  in  spite  of  local  and  general 


520  DISEASES   OF    THE    EXTERNAL    GENITALS   AND   VAGINA 

sedatives  and  in  some  cases  they  become  intolerable,  making  the  patient's  life 
a  burden  to  her.  On  account  of  the  irresistible  tendency  to  scratch  or  rub 
the  parts,  the  skin  becomes  irritated  and  abraded  and  inflamed.  Deep  fis- 
sures may  form  and  in  some  cases  a  discharging  or  weeping  surface  develops, 
to  be  followed  by  scar-tissue.  The  constant  suffering  makes  the  patient  irri- 
table and  nervous  and  in  some  eases  leads  eventually  to  nervous  prostration. 
Treatment.  The  treatment  for  pruritus  vulvae  may  be  presented  in  the 
following  steps : 

1.  Eemove  All  Local  Causes  op  Ieritation,  These  have  been  enumerated 
under  etiology.  If  an  irritating  vaginal  discharge  is  present  it  must  be 
stopped  by  appropriate  treatment  of  the  disease  causing  it.  If  that  is  not 
possible,  the  discharge  may  be  kept  from  irritating  the  genitals  by  washing 
it  away  with  antiseptic  douches.  Sometimes  it  is  advisable,  after  the  douche, 
to  introduce  a  tampon  Avhich  prevents  the  discharge  from  coming  in  contact 
with  the  external  genitals.  The  tampon  is  removed  at  the  next  douche  time. 
The  tampon  may  be  used  dry  or  it  may  be  saturated  with  borax  and  glycerine 
(1  to  4)  or  with  acetate  of  lead  and  glycerine  (1  to  4)  or  with  ichthyol-gly- 
cerine  (10%  to  25%).  The  importance  of  vaginal  discharge  as  a  causative 
factor  in  pruritus  is  not  so  great  as  might  at  first  be  supposed.  In  fact,  it  is 
very  doubtful  if  ordinary  leucorrheal  discharge  alone  ever  causes  sever©  pru- 
ritus. In  each  case  there  is  probably  some  other  more  important  factor.  In  a 
case  of  pruritus  presenting  a  vaginal  discharge,  the  discharge  has  some  effect 
in  keeping  up  the  local  irritation  and  consequently  should  be  stopped.  But 
there  is  no  certainty  that  the  pruritus  will  cease  when  the  discharge  is  stopped, 
hence  caution  in  prognosis  is  necessary.  Other  causes  of  local  irritation,  such 
as  diabetes,  local  skin  diseases  and  uterine  or  ovarian  disease  causing  pelvic 
congestion,  must  receive  appropriate  treatment. 

2.  Attend  to  the  General  Health.  Regulate  the  bowels  so  that  the 
accompanying  pelvic  congestion  is  diminished.  Also,  put  the  patient  in  the 
best  general  health,  that  the  condition  of  the  nervous  system  may  be  improved 
accordingly.  General  sedatives,  for  example,  bromides,  valerian,  hyoscyamus, 
may  diminish  the  itching  by  their  effect  on  the  nervous  system.  The  anti- 
neuralgic  remedies  (phenacetin,  antipyrin),  may  give  temporary  relief. 

Uric  acid  diathesis,  neurasthenia,  gastro-intestinal  disturbance  and  other 
diseases  present  must  receive  appropriate  treatment.  The  diet  must  be  looked 
after  sufficiently  to  exclude  alcoholics  and  other  articles  that  tend  to  prolong 
skin  irritation. 

In  some  cases  it  may  be  necessary  to  make  a  complete  change  of  climate 
and  surroundings,  in  order  to  satisfactorily  affect  the  patient's  nervous  system 
or  some  existing  diathesis. 

3.  Employ  Local  Sedative  Applications  to  relieve  the  inflammation  and 
check  the  local  nerve  irritation. 

The  various  applications  given  under  vulvitis  and  other  forms  of  vulvar 


PRURITUS   VULVAE  521 

irritation  may  be  tried.  The  silver  preparations  (silver  nitrate,  argyrol,  pro- 
targol)  are  particularly  effective,  when  there  is  active  superficial  inflamma- 
tion. If  follicular  inflammation  is  present,  the  inflamed  follicles  may  be 
emptied  by  puncture  and  the  small  cavities  touched  with  silver  nitrate  solu- 
tion (10%)  or  even  with  the  silver  nitrate  stick.  The  thorough  applications 
of  silver  nitrate  solution  (10%)  or  protargol  (10%)  sometimes  gives  decided 
relief  from  pruritus  even  when  no  inflammation  is  present. 

A  useful  mixture  for  washing  out  the  vagina  and  for  an  external  Avash  in 
these  cases  is  the  lead  and  opium  and  carbolic  acid  mixture.  Cold  applica- 
tions, such  as  an  ice  bag  or  cloths  wet  in  ice  water,  sometimes  give  relief. 
Warm  sitz-baths  of  plain  water,  taken  two  to  four  times  daily,  aid  in  keep- 
ing the  parts  clean  and  also  tend  to  relieve  the  local  inflammation  and  irrita- 
tion. Instead  of  plain  water  the  vaginal  wash  just  mentioned  may  be  used  in 
the  sitz-bath.  In  some  cases  the  addition  of  ordinaiy  bran  seems  to  increase 
the  soothing  etfect  of  the  sitz-bath.  The  patient  may  remain  in  the  sitz-bath 
from  10  to  30  minutes,  the  fluid  being  occasionally  injected  into  the  vagina 
if  there  is  much  internal  irritation. 

Most  cases  require  additional  applications  which  are  more  strongly  seda- 
tive or  anesthetic  or  stimulating,  as  the  case  may  be. 

Skene  recommends  the  following,  each  of  which  has  been  used  with 
benefit.  Bichloride  in  almond  oil,  morphine  and  chalk  powder,  opium  and 
aconite  mixture.  Of  these  preparations,  the  bichloride  in  almond  oil  proved 
beneficial  in  the  largest  number  of  cases.  When  this  fails,  iodoform  in  ether 
(1  to  4)  or  carbolic  acid  and  tincture  of  iodine  (equal  parts)  may  be  applied 
by  the  physician. 

The  iodoform  in  ether  is  applied  by  means  of  an  atomizer.  By  using 
strong  air  pressure  the  solution  is  forced  into  all  the  folds  of  the  epidermis  or 
mucous  membrane.  The  ether  evaporates,  leaving  a  fine  coating  of  iodoform 
over  the  whole  surface.  This  nearly  ahvays  relieves  considerably  and,  if  ap- 
plied frequently,  is  curative  in  some  cases.  The  carbolic  and  iodine  mix- 
ture is  applied  thoroughly  to  all  the  involved  surface  by  means  of  a  camel's- 
hair  brush  or  a  small  piece  of  cotton  on  an  applicator.  This  is  very  effective 
in  relieving  the  pruritus,  but  is  liable  to  cause  considerable  local  irritation  and 
dermatitis.  It  should  not  be  reapplied  until  the  irritation  from  the  first  ap- 
plication has  subsided. 

Skene  gives  an  account  of  one  case  of  severe  pruritus  in  which  he  used 
the  carbolic  and  iodine  mixture  with  the  ordinary  method  of  application,  as 
given  above,  but  found  it  difficult  to  get  the  medicine  into  all  the  irregu- 
larities. Consequently,  he  applied  it  hy  means  of  the  atomizer,  using  high 
pressure.  The  first  effect  was  a  sharp  pain  followed  by  numbness  of  the  parts 
and  relief  from  the  itching.  Later,  there  was  great  irritation  and  pain,  and 
the  superficial  layers  of  the  skin  and  mucous  membranes  came  off,  as  though 
they  had  been  blistered.     The  patient  stated,  however,  that  even  when  the 


522  DISEASES   OF    THE   EXTERNAL   GENITALS    AND   VAGINA 

pain  from  the  irritation  was  at  its  height,  it  caused  far  less  suffering  than  the 
previous  itching.  When  the  patient  recovered  from  the  treatment,  the  itching 
did  not  return  for  several  weeks  and  then  only  in  slight  degree.  The  same 
application  was  again  made  to  several  spots  that  were  itching,  care  being 
taken  not  to  cover  more  than  a  small  area.  The  result  of  the  two  applications 
was  a  complete  recovery  from  the  intolerable  pruritus. 

In  irritation  from  diabetic  urine,  bismuth  subnitrate,  either  alone  or 
mixed  with  an  equal  quantity  of  prepared  chalk,  is  an  excellent  application. 
Direct  the  patient  to  prevent,  as  far  as  possible,  the  urine  from  running  over 
the  parts,  and  immediately  after  urination  to  wash  the  parts  with  a  carbolic 
wash  and  then  dry  carefully  and  dust  on  the  powder  freely. 

Ravogli  recommends  the  follo-^A'ing  additional  measures  in  vulvar  irrita- 
tion from  various  causes : 

A  carbolic  and  sulphur  ointment  when  the  irritation  is  due  to  diabetic 
urine.  For  the  same  purpose  a  liniment  of  oil  and  limewater,  with  2%  to 
4%  ichthyol  added,  is  recommended,  to  be  applied  when  the  patient  can  re- 
main in  bed.  When  the  patient  can  not  remain  in  bed,  some  protective  oint- 
ment such  as  benzoated  oxide  of  zinc  ointment  or  the  zinc  and  subcarbonate 
of  bismuth  ointment  may  be  used. 

When  eczema  is  present,  direct  the  patient  to  irrigate  the  vagina  with  a 
5%  solution  of  borax  twice  daily.  Every  other  day  insert  into  the  vagina  a 
tampon  saturated  in  a  mixture  of  25%  ichthyol  in  glycerine,  the  tampon  to 
be  left  in  the  vagina  twelve  hours.  To  relieve  the  itching  and  sterilize  the 
skin  apply  the  carbolic  and  alcohol  mixture.  This  causes  some  burning  at 
first  but  soon  affords  relief.  After  this  application  direct  the  patient  to  apply 
pieces  of  lint  saturated  with  the  ichthyol  and  almond  oil  liniment.  When  the 
itching  has  disappeared  and  the  eczema  is  nearly  well,  the  ichthyol  liniment 
may  be  discontinued  and  the  zinc  and  bismuth  ointment  used.  After  the 
eczema  has  disappeared,  the  parts  should  be  frequently  cleansed  with  a  car- 
bolic solution  and  dusted  freely  with  some  drying  powder. 

When  there  is  persistent  follicular  inflammation,  the  carbolic  and  bismuth 
and  mercury  ointment  is  useful.  Ichthyol  is  also  highly  recommended  either 
as  the  liniment  or  in  the  form  of  a  salve  (10%)  in  association  with  the  zinc 
ointment  and  2%  beta-naphthol.  Ointments  containing  sulphur  also  are  recom- 
mended, such  as  Lassar's  paste.  The  result  of  treatment  for  pruritis  vulvae 
is  very  uncertain  and  measures  that  are  efficient  in  one  case  may  fail  com- 
pletely in  another.  The  author  has  obtained  good  results  from  an  ointment 
of  chloretone  (10%).  Much  relief  may  be  afforded  also  by  orthoform  oint- 
ment (10%)  and  by  cocaine  ointment  (1%  to  10%).  Electricity  has  given 
relief  in  some  cases,  and  it  is  well  to  try  it  in  a  variety  of  applications. 

The  X-ray  treatment,  when  available,  should  be  given  a  thorough  trial  in 
severe  pruritus  cases,  before  resorting  to  operative  measures. 

4.  Operations.  In  certain  intractable  cases,  particularly  those  accom- 
panied by  evidences  of  kraurosis  vulvae,  relief  was  afforded  by  excision  of 


HYPERESTHESIA   OF    THE   VAGINAL   ENTRANCE  523 

the  involved  tissues  as  previously  described,  after  the  other  measures  had 
failed.  When  incision  is  resorted  to,  it  is  as  a  rule  necessary  to  remove  the 
labia  minora  and  the  clitoris  with  its  prepuce,  and  often  the  inner  portions  of 
the  labia  majora. 

Another  operative  measure  which  has  brought  about  recovery  in  some 
cases,  is  resection  of  the  internal  pudic  nerve.  The  nerve  is  reached  by  an 
antero-posterior  incision  midway  between  the  tuberosity  of  the  ischium  and 
the  anus.  Care  must  be  taken  that  the  innervation  of  the  rectum  be  not 
damaged,  with  resulting  incontinence  of  feces. 

HYPERESTHESIA  OF  THE  VAGINAL  ENTRANCE 

The  structures  surrounding  the  vaginal  orifice  may  be  so  hyperesthetic, 
that  coitus  is  very  painful  and  in  some  cases  impossible.  Occasionally  the 
parts  are  so  tender  and  the  nervous  irritability  so  marked  that  attempts  at 
sexual  intercourse  cause  a  spasm  of  the  muscles  surrounding  the  vaginal 
opening,  including  the  levator  ani.  This  spasmodic  condition  is  known  as 
''vaginismus." 

Causes.  Hyperesthesia  of  the  vaginal  entrance  occurs  most  frequently  in 
nervous  young  women,  newly  married,  or  in  women  near  the  menopause.  The 
causes  of  this  marked  hypersensitiveness  are  as  follows: 

a.  Urethral  caruncle  or  inflammation  about  the  meatus, 

b.  Painful  fissures  about  the  vaginal  orifice  or  about  the  anus. 

c.  Inflammation  of  a  rigid  hymen  or  of  remnants  of  a  hymen. 

d.  Abnormal  form  of  vulva  by  which  the  penis  is  directed  in  the  wrong 
direction,  particularly  against  the  urethra,  causing  much  pain. 

e.  Neuromata  on  remnants  of  the  hymen. 

f.  Neuroses.  In  some  cases,  especially  in  women  near  the  menopause,  no 
local  cause  for  the  marked  sensitiveness  can  be  discovered  and  it  is  apparently 
due  to  some  functional  disturbance  of  the  nerves. 

Treatment.    The  treatment  may  be  presented  in  the  following  steps: 

1.  Keduce  the  general  nervous  irritability  by  sedatives  and  relieve  the 
pelvic  congestion  by  laxatives. 

2.  Kemove  all  local  lesions  that  cause  irritation.  Abrasions,  fissures  and 
areas  of  inflammation  must  be  made  to  heal.  The  various  therapeutic  measures 
for  these  conditions  have  been  described.  A  rigid  hymen  must  be  treated  by 
stretching  or  incision  or  excision. 

Neuromata  sometimes  develop  in  remnants  of  the  hymen  about  the  pos- 
terior commissure,  and  occasionally  in  the  tissues  about  the  meatus  or  the 
clitoris.  There  may  be  one  or  more  nodules,  varying  in  size  from  the  head  of 
a  pin  to  a  bean.  They  are  exceedingly  sensitive  when  touched  in  the  examina- 
tion. They  should  be  excised  deeply  and  the  small  wound  closed  by  one  or 
two  sutures  if  there  is  much  bleeding.    Ten  to  twenty  drops  of  cocaine  solu- 


524  DISEASES    OF    THE   EXTERNAL    GENITALS    AND   VAGINA 

tion  (1/2%)  injected  under  the  nodule  a  few  minutes  before  excision  dimin- 
ishes the  pain.  If  the  nodule  can  be  easily  raised  it  may  be  clipped  off  with 
the  scissors.  If  it  is  imbedded  in  the  tissues,  it  must  be  dissected  out  with  a 
knife. 

3.  Employ  local  sedative  applications.  A  hot  carbolic  douche,  once  or 
twice  daily,  may  diminish  the  sensitiveness  of  the  parts.  The  various  sedative 
measures  mentioned  under  vulvitis  and  pruritus  vulvae  may  be  employed. 
The  10%  chloretone  ointment  may  give  much  relief.  A  cocaine  suppository 
introduced  into  the  vagina  a  few  minutes  before  may  diminish  or  remove  the 
pain  of  coitus.  A  cocaine  ointment  (5%)  may  be  applied  to  the  sensitive 
parts  with  the  same  effect.  The  ointment  applied  freely  serves  also  to  lubri- 
cate the  parts  and  in  that  way  helps  to  diminish  the  pain. 

"When  this  affection  occurs  in  a  young  married  woman,  if  the  patient  be- 
comes pregnant  and  is  delivered  at  term,  the  vaginismus  will  probably  be 
heard  of  no  more.  Consequently,  if  by  temporary  measures  the  pain  of 
sexual  intercourse  can  be  overcome  for  a  few  weeks,  pregnancy  may  take 
place  and  a  permanent  cure  follow. 

In  some  mild  cases  the  patient  may  be  given  relief  or  even  cured  by  in- 
troducing a  bivalve  speculum  every  second  or  third  day,  and  very  slowly  and 
carefully  stretching  the  parts  until  decided  discomfort  is  noticed.  No  severe 
pain  should  be  caused,  as  the  patient  may  be  frightened  and  made  M^orse. 
After  the  gentle  stretching,  a  small  tampon,  with  the  upper  end  soaked  in 
boro-glyceride,  should  be  placed  in  the  upper  part  of  the  vagina.  This  tam- 
pon should  be  small  at  first  but  as  new  ones  are  placed  they  may  be  gradually 
increased  in  size  until  the  vagina  is  firmly  filled,  but  the  tampon  must  not 
come  low  enough  to  make  troublesome  pressure  on  the  vaginal  entrance. 

4.  Forcible  Dilatation.  "When  the  milder  measures  fail  to  give  relief  the 
patient  should  be  anesthetized  and  the  A^aginal  entrance  forcibly  stretched 
with  the  fingers  or  with  a  bivalve  speculum.  The  speculum  is  introduced  and 
opened  and  then  withdra^^ai  while  the  blades  are  widely  separated.  Any 
abrasions  remaining  after  the  stretching  should  be  touched  with  carbolic  acid 
and  an  antiseptic  dressing,  of  absorbent  cotton  or  gauze,  should  be  kept  over 
the  vulva  until  all  the  abrasions  have  healed.  After  the  stretching,  a  vaginal 
plug  of  glass  is  introduced  every  day  for  a  time  to  prevent  contraction  of  the 
healing  tissues. 

When  forcibly  stretching  the  vaginal  orifice,  if  there  are  fibers  that  do 
not  yield  readily  they  may  be  divided  subcutaneously  with  a  bistoury.  In 
some  cases  in  which  the  opening  is  narrow  and  the  perineum  rigid,  it  is  ad- 
visable to  employ  the  method  devised  by  Sims,  namely,  excision  of  a  V-shaped 
piece  of  tissue  at  the  posterior  margin  of  the  vaginal  opening.  This  gives  a 
result  corresponding  to  slight  laceration  of  the  perineum  in  labor  and  is  of 
much  benefit.  It  gives  a  larger  vaginal  opening  but  does  not  interfere  to  any 
extent  ^vith  the  integrity  of  the  pelvic  floor.     In  those  cases  in  which  the 


ADHESIONS    OF    LABIA  525 

hyperesthesia  is  due  to  abrasions,  principally  in  young  Avomen,  this  forcible 
stretching  is  very  effective. 

In  the  purely  neurotic  cases,  chiefly  in  women  near  the  menopause,  it 
may  produce  but  little  result.  Sujch  cases  are  exceedingly  rebellious  and  oc- 
casionally persist  in  spite  of  all  treatment.  Complete  excision  of  the  skin 
covering  all  hyperesthetic  areas,  gives  temporary  relief,  but  the  trouble  may 
return  after  a  few  months. 

In  the  intractable  cases,  the  treatment  that  promises  most  relief  is  ex- 
cision of  the  skin  over  the  affected  areas  and  then,  or  as  soon  as  the  parts  have 
healed  sufficiently,  send  the  patient  away  from  home  to  where  there  will  be 
an  enjoyable  change  of  air  and  scenery  and  environment.  Advise  regular  and 
moderate  exercise  and  a  nourishing  but  unstimulating  diet.  Forbid  exces- 
sive exercise  and  forbid  sexual  intercourse  or  sexual  excitement.  Kegulate 
the  bowels,  give  tonics  and  allay  the  local  disturbance  temporarily  by  the 
cleansing  and  sedative  measures  previously  described.  Resection  of  the  in- 
ternal pudic  nerve  may  give  relief  in  an  intractable  case. 

ADHESIONS  OF  PREPUCE 

Not  infrequently  in  infants  adhesions  are  found  between  the  glands  of 
the  clitoris  and  the  prepuce.  In  some  cases  the  adhesions  are  extensive  (Fig. 
206)  and  much  irritation  is  produced  by  retained  secretion,  not  so  rarely 
forming  the  underlying  cause  for  the  habit  of  masturbation  innocently  ac- 
quired by  a  child.  In  such  a  case  the  adhesions  should  be  separated.  A  strong 
solution  of  cocaine  (10%  to  20%)  is  applied  to  the  parts  for  five  minutes,  then 
with  a  blunt  dissector,  the  adhesions  are  broken,  the  glans  thoroughly  ex- 
posed (Fig.  224)  and  the  part  cleansed  and  smeared  with  carbolized  zinc 
ointment  (2%)  or  with  carbolized  vaseline  (2%).  Every  day  or  two  the  pre- 
puce should  be  pushed  back  and  the  antiseptic  ointment  applied,  until  there  is 
no  further  danger  of  the  formation  of  new  adhesions. 

ADHESIONS  OF  LABIA 

The  labia  minora  are  occasionally  found  adherent.  This  condition  may 
be  congenital  or  acquired.  In  the  latter  case,  the  cause  is  inflammation  or 
ulceration  of  various  kinds,  producing  raw  surfaces  which  come  in  contact 
and  grow  together  (Fig.  208).  The  adhesions  are  usually  found  in  the  un- 
married, as  the  parts  are  not  so  frequently  disturbed,  and  especially  in  chil- 
dren and  in  the  aged,  when  considerable  irritation  may  persist  without  at- 
tracting notice.  The  adhesions  between  the  labia  are  easily  broken  if  recent, 
but  later  the  adherent  surfaces  become  firmly  united  by  connective  tissue  and 
can  be  separated  only  with  the  knife.  The  treatment,  when  the  adhesions  are 
recent  and  weak,  is  to  break  them  with  a  probe  or  other  blunt  instrument, 
separate  the  labia  and  keep  them  apart  with  pledgets  of  cotton.     Treat  the 


526  DISEASES   OF    THE   EXTERNAL   GENITALS   AND   VAGINA 

affected  surfaces  as  indicated  by  the  inflammation  or  ulceration  present. 
When  the  adhesions  are  old  and  firm,  the  parts  may  be  separated  with  the 
knife  or  scissors,  or  the  line  of  union,  with  some  of  the  thickened  tissue  on 
each  side,  may  be  excised,  sutures  being  then  introduced  to  check  the  hemor- 
rhage and  close  the  raw  surfaces.  If  there  is  a  marked  tendency  of  the 
vaginal  orifice  to  contract  from  scar-tissue,  it  may  be  stretched  at  the  same 
time,  and  a  glass  plug  worn  for  a  time  afterward  if  necessary. 


CHAPTER  Y 

RELAXATION  AND  FISTULAE 

of  the  Pelvic  Floor,  Perineum,  External  Genitals  and  Vagina 

POINTS  IN  ANATOMY 

The  term  ''pelvic  floor"  is  applied  to  that  group  of  structures  which 
closes  in  the  pelvic  outlet  and  supports  the  structures  above  it.  The  muscu- 
lar and  fascial  layers  are  shown  in  Fig.  467.  The  important  structures — those 
that  give  strength  to  the  floor — are  principally  the  levator  ani  muscles  and  the 
recto-vesical  fascia.  There  are,  however,  a  number  of  other  structures  in  this 
locality,  and  probably  the  best  way  to  consider  them  systematically  is  to  take 
them  up  in  the  order  in  which  they  are  met  with  in  the  regular  dissection  of 
this  region. 

Having  the  body  in  position  for  dissection  of  the  perineum  and  making 
observation  before  the  integument  is  removed,  it  is  found  that  the  area  be- 
tween the  coccyx  and  the  pubes  is  filled  in  as  follows,  beginning  in  front : 
The  vulva  or  external  genitals. 
The  perineum. 

The  anus  and  the  ischio-rectal  fossa  of  each  side  (covered  with  in- 
tegument). 

The  vulva  and  perineum  occupy  the  anterior  half  of  the  space.  The 
anus  is  situated  at  about  the  center,  and  around  it  to  the  sides  and  behind,  are 
the  ischio-rectal  fossae. 

The  external  genitals  have  been  described  in  Chapter  iv.  The  perineum 
is  the  wedge  of  tissue  situated  between  the  vagina  and  the  lower  portion  of 
the  rectum.  Seen  in  the  antero-posterior  section,  it  is  roughly  triangular 
(Figs.  1,  3,  582).  In  some  cases  it  is  somewhat  quadrilateral.  It  separates 
the  vaginal  opening  from  the  rectal  opening,  but  does  not  form  an  essential 
part  of  the  real  supporting  floor  of  the  pelvis. 

The  removal  of  the  skin  and  superficial  fat  and  fascia,  exposes  the  perineal 
fascia,  the  sphincter  ani  muscle  and  the  ischio-rectal  fossa  of  each  side.  Each 
ischio-rectal  fossa  is  bordered  behind  and  at  the  outer  side  by  the  gluteus 
maximus  muscle. 

Eefleeting  the  perineal  fascia  there  are  exposed,  the  sphincter  vaginae  and 
the  transversus  perinei  muscles  (Fig.  468).  The  transversus  perinei  muscle 
of  each  side  is  a  small  muscular  band  which  arises  from  the  ischial  tuberosity 
and,  extending  inward,  joins  at  the  center  of  the  perineum  with  the  muscle 

627 


528 


RELAXATION    AND    FISTULAE 


of  the  opposite  side  and  with  the  sphincter  vaginae  and  with  the  sphincter  ani 
muscles.  When  the  perineum  is  torn,  the  action  of  all  these  muscles,  particu- 
larly of  the  transverse  muscles,  is  to  draw  the  torn  surfaces  outward  and  keep 
them  apart. 

When  all  the  superficial  tissues,  including  the  clitoris  and  the  crura,  are 
cleared  away,  then  there  is  exposed  the  real  pelvic  floor — the  supporting 
structures.  These  structures  are,  the  levator  ani  muscles,  one  on  each  side 
(Fig.  469)  called  also  the  levator  ani  and  vaginae,  and  the  fascia  above  and 
below  them  (Figs.  470,  471).    The  fascia  under  the  muscle  is  thin  and  is  called 


Fig.   467.     A     diagrammatic     representation     of     an     antero-posterior     section     of    the     pelvis,     showing     the 
various    Fascial    Layers    of    the    Pelvic    floor.       (Dickinson — American    Textbook    of    Obstetrics.) 


the  "levator  fascia,"  while  the  strong  fascia  above  the  muscle  is  called  the 
" recto-vesical' '  (Fig.  470).  The  levator  ani  muscles,  arising  from  each  side 
of  the  pelvis  and  joining  in  the  median  line,  form  a  sling  which  holds  up 
the  vagina  and  rectum  and  at  the  same  time  holds  their  lower  ends  forward 
under  the  pubic  arch. 

Each  levator  ani  muscle  arises  in  front  from  the  posterior  surface  of  the 
pubic  bone,  behind  from  the  spine  of  the  ischium  and  betAveen  these  points 
from  the  "Avhite  line"  (Fig.  83)  that  marks  the  division  of  the  pelvic  fascia. 
The  anterior  portion  of  the  muscle  passes  downward  and  toward  the  median 


POINTS   IN   ANATOMY 


529 


Suspensory  ligament  of  clitoris 
Glans  clitoridis, 
Posterior  superficisl  perine?.!  n 

Fascia  lata 
iferior  pudendal  n.^  \ 


Spliincter  vaginae  o, 


Obturator  fascia 


iDorsal  nerve  of  clitoris 

iite-'i  \\  D.udi-  a.  ; 


TransverPe  jjcnj^i.  ,'  '^i 


Fig.  468.     View  of  the  superficial  structures  from  below.      Showing  the   Sphincter  Ani  Muscle,  the   Trans- 
versus  Perinei  Muscles  and  the  Arteries  and  Nerves.      (Deaver — Surgical  Anatomy.) 


530 


EELAXATIOX    AXD    FISTULAE 


Fig.    469.     The  superficial   structures   removed,  exposing  the   Levator  Ani   and   \'aginae    Muscles.      (Savage- 

Anatomy    of    Female    Pelvic    Organs.) 


Fig.   470.     The    Levator   Ani    Muscles    removed,    exposing    the    strong    Recto-vesical    Fascia.       (Savage- 

Anatomy   of  Female  Pelvic   Organs.) 


POINTS   IN   ANATOMY 


531 


Fig.  471.  The  Pelvic  Sling.  It  is  composed  of  the  Levator  Ani  Muscles  and  the  Fascia  above  and 
below  them.  Its  attachment  to  the  rectum  is  here  shown  but  the  vagina  is  not  shown.  (Kelly — Opera- 
tive   Gynecology.)     ' 


C^c, 


lS'-"~  iaSi/ 


•**-      ..ftrmimomslUta'^ 


Fig.  472.     The    Pelvic    Sling,    formed    by    the    lycvator    Ani 
Muscles.      (Dickinson — American   Xe-'<-'tbook    of   Obstetrics.) 


Fig.  473.  Actions  of  the  Pelvic  Sling. 
It  tends  to  draw  the  vaginal  opening  and 
the  anus  forward  under  the  pubic  arch,  at 
the  same  time  that  it  supports  them.  (Kelly 
— Operative  Gynecology.) 


532 


BELAXATIOK   AND   FISTULAE 


Fibio 


Sohincter  vesicj;  m. 
and  neck  of  biadder 


SacrLmI 


Pubic  bone 


Obturator  fascia 
Obturator  canal 


Fig.  474.  The  Pelvic  Sling,  from  above.  The  observer  is  supposed  to  be  standing  at  the  right 
side  of  the  cadaver  and  looking  into  the  pelvis.  The  pelvic  contents  have  been  removed  in  order  to 
show   the   pelvic   floor.      (Deaver — Surgical   Anatomy.) 


RELAXATION  OF  PELVIC  FLOOR  533 

line  and  unites  with  a  corresponding  portion  of  the  muscle  of  the  opposite 
side.  Some  of  the  fibers  unite  with  the  lower  part  of  the  vagina,  some  with 
the  lower  part  of  the  rectum,  some  betAveen  the  vagina  and  rectum  and  many 
of  them  back  of  the  rectum.  The  most  posterior  fibers  of  the  muscle  unite 
Avith  the  coccyx.  Lying  back  of  the  posterior  part  of  the  levator  ani  muscle  is 
the  coccygeus  muscle.  The  action  of  the  levator  muscles,  in  conjunction  with 
the  fascia  above  and  below  them,  is  to  hold  forward  the  lower  end  of  the 
rectum  and  vagina  close  to  the  symphysis  pubis,  and  at  the  same  time  to  form 
a  sling  which  closes  the  pelvic  outlet  and  supports  the  organs  above  (Figs. 
471,  472,  473,  474).  Waldeyer  has  given  this  the  very  appropriate  designa- 
tion of  "diaphragm  of  the  pelvis." 

When  the  muscles  and  fasciae  are  torn,  the  effect  is  two-fold : 

1.  The  sling  is  lengthened  and  does  not  furnish  the  support  it  previously 
did. 

2.  The  vaginal  and  rectal  openings  (the  weak  places  in  the  pelvic  floor) 
are  alloAved  to  sink  backward  into  the  line  of  pressure,  so  that  the  weight 
from  above,  which  formerly  fell  on  the  muscle  and  fascia,  now  falls  on  the 
openings. 

In  repairing  the  pelvic  floor,  the  folloAving  two  things  must  be  accom- 
plished : 

1.  The  pelvic  sling  must  be  shortened,  so  that  the  slack  is  taken  up. 

2.  The  vaginal  opening  must  be  brought  forward  under  the  pubic  arch, 
out  of  the  line  of  direct  pressure. 

RELAXATION  OF  THE  PELVIC  FLOOR 

For  this  common  gynecologic  condition,  so  frequently  requiring  opera- 
tion, the  author  prefers  the  term  ''relaxation"  rather  than  "laceration,"  for 
the  f olloAving  reasons : 

a.  It  is  the  presence  or  absence  of  relaxation  that  determines  the  neces- 
sity for  treatment.  Even  though  there  is  immediate  repair  and  perfect  heal- 
ing of  the  laceration  there  may,  through  subinvolution  and  lack  of  tone,  be 
persisting  relaxation  requiring  operation.  Again,  with  an  unrepaired  lacera- 
tion, the  contraction  of  scar-tissu©  and  regaining  of  tone  may  be  sufficient  to 
give  good  support,  and  there  is  no  relaxation — hence,  no  cause  for  operation. 
The  essential  lesion,  then,  considered  from  the  therapeutic  standpoint,  is  the 
relaxation. 

b.  The  term  "laceration"  as  commonly  used,  and  as  interpreted  by  the 
patient,  often  works  an  injustice  to  the  physician  who  took  care  of  the  pa- 
tient during  confinement.  In  a  considerable  proportion  of  cases  the  patient 
comes  to  the  gynecologist  with  her  mind  poisoned  against  her  former  phy- 
sician because  some  other  physician  has  told  her,  bluntly  and  without  qualifi- 
cation, that  her  present  trouble  is  due  to  having  been  "torn  in  labor."  The 
average   patient   interprets   this   as   conclusive   evidence   of   faulty   care,     In 


534 


RELAXATION"    AND   FISTULAE 


fact,  she  not  infrequently  begins  her  story  with  the  statement  that  her  trouble 
is  due  to  neglect  in  confinement — this  she  knows  because  of  having  been 
informed  that  she  was  suffering  from  "a  laceration." 

Now,  as  a  matter  of  fact,  this  wholesale  condemnation  is  not  warranted. 
Of  course,  in  some  cases  the  relaxation,  for  which  the  patient  seeks  relief,  is 
really  due  to  the  fact  that  an  extensive  tear  was  not  repaired  at  all  or  was 
repaired  in  a  faulty  manner.  However,  in  a  considerable  proportion  of  the 
cases,  the  relaxation  is  due  to  entirely  different  causes.  There  may  have 
been  no  open  laceration,  the  overstretching  having  been  accomplished  by  sub- 
mucous lacerations  (many  or  few)  which  could  not  even  be  located,  much  less 
repaired.  Again,  if  pelvic  floor  involution  is  imperfect,  as  it  often  is  in  atonic 
patients,  marked  relaxation  may  result  without  there  having  been  any  definite 
lacerations,  either  open  or  submucous.  This  form  of  relaxation  is  especially 
apt  to  occur  if  the  patient  has  repeated  pregnancies  at  short  intervals.  Again, 
in  certain  cases,  laceration  or  division  of  tissue  must  necessarily  accompany 
delivery  of  the  child.  The  wounds  may  fail  to  heal  satisfactorily  in  spite  of 
the  utmost  care.  Again,  a  pelvic  floor  which  is  good  two  months  after  labor 
may  be  found  greatly  relaxed  later,  owing  to  displacement  of  the  uterus  or  to 
heavy  lifting  (as  of  a  heavy  child)  or  to  persistent  straining  or  coughing  asso- 
ciated with  an  atonic  condition  of  the  tissues.  These  facts  are  well  known  to 
every  physician  who  has  made  a  real  study  of  the  anatomy  of  the  pelvis  and  of 
the  physiology  and  pathology  of  parturition. 

In  view  of  the  above  facts,  it  is  incumbent  upon  us  to  employ  some  term, 
for  the  condition  under  consideration,  which  does  not  in  itself  carry  con- 
demnation to  the  mind  of  the  patient.  ''Relaxation"  is  such  a  term.  It  sim- 
ply designates  clearly  the  condition  demanding  relief,  leaving  open  the  ques- 
tion as  to  which  one  of  the  above  mentioned  causes  may  have  been  present  in 
that  particular  case. 

Etiolog-y 

The  usual  cause  of  laceration  of  the  pelvic  floor  and  perineum  is  child- 
birth. As  the  child 's  head  passes  through  the  pelvic  outlet,  the  structures  are 
greatly  stretched  and,  if  it  is  the  first  baby,  there  is  frequently  more  or  less 
laceration.  In  many  cases  the  laceration  is  so  slight  as  to  be  hardly  notice- 
able. In  some  cases  it  is  moderate  and  will  cause  trouble  later  if  not  repaired. 
In  a  few  cases  it  is  very  severe,  extending  deeply  into  the  sides  of  the  pelvis 
or  into  the  rectum  or  into  both  regions. 

Pathology  and  Diagnosis 

To  understand  the  pathology  of  this  affection,  certain  points  in  anatomy 
must  be  kept  in  mind.  The  real  pelvic  floor,  that  is,  the  part  that  supports 
the  organs  above,  is  formed  by  the  two  levator  ani  muscles  with  the  layer  of 
fascia  immediately  above  and  below   (Figs.  467,  471,  472,  473).     The  recto- 


RELAXATION  OF  PELVIC  FLOOR  535 

vesical  fascia  is  a  strong  fibrous  layer,  probably  the  strongest  and  most  re- 
sistant single  element  in  the  pelvic  floor.  It  evidently  is  the  structure  which 
furnishes  continuous  support  to  the  organs  above,  for  the  muscles  of  the  floor 
can  not  be  constantly  tense. 

The  perineum  takes  little  part  in  the  formation  of  the  pelvic  floor,  as  it 
lies  below  and  outside  of  the  supporting  sling.  The  perineum  may  be  torn 
with  practically  no  damage  to  the  pelvic  floor,  providing  the  anterior  part  of 
the  levator  aui  muscles  or  adjacent  fasciae  are  not  involved  in  the  tear.  It  is 
not  the  tearing  of  the  perineum  that  destroys  the  integrity  of  the  pelvic  floor, 
but  the  tearing  and  stretching  of  the  musculo-fibrous  sling  which  passes  back 
of  the  rectum  and  holds  both  the  rectum  and  vagina  well  up  under  the  sym- 
physis (Fig.  473). 

The  pathologic  changes  and  the  diagnostic  points  are  best  considered 
together  under  the  different  varieties  of  laceration.  Immediately  after  the 
delivery  of  the  child  and  placenta,  search  should  be  made  for  tears  of  the 
perineum  and  pelvic  floor. 

Varieties  of  Laceration 

There  are  several  varieties  of  laceration,  differing  in  extent  and  location. 

1.  There  may  be  a  slight  tear  of  the  perineum  only,  involving  less  than 
half  of  the  perineum.  The  f  ourchette  is  torn  and  also  part  of  the  skin  covering 
the  perineum  and  also  the  lower  portion  of  the  posterior  vaginal  wall.  Such 
a  tear  has  practically  no  effect  on  the  pelvic  floor,  as  the  pelvic  floor  proper 
is  not  involved.  It  is  called  a  laceration  of  the  perineum  of  the  "first  de- 
gree. ' ' 

2.  There  may  be  a  tear  down  past  the  middle  of  the  perineum — laceration 
of  "second  degree."  This  may  involve  the  perineum  only,  in  which  case  there 
is  no  decided  damage  to  the  pelvic  floor.  Usually,  however,  the  tear  ex- 
tends up  the  vaginal  sulcus  of  one  or  both  sides  and  involves  the  front  part  of 
the  levator  ani  muscle  and  recto-vesical  fascia  (Figs.  475,  478).  The  lacera- 
tions involving  the  muscular  and  fibrous  structures  at  the  sides  of  the  vagina 
are  sometimes  spoken  of  as  "lateral"  or  "transverse"  lacerations.  The  lacera- 
tions of  the  muscle  and  fascia  may  be  open,  communicating  with  a  vaginal 
tear,  or  subcutaneous,  with  no  vaginal  tear  in  the  immediate  vicinity.  By 
washing  the  blood  out  of  the  vagina  with  a  hot  douche  and  exploring  with  the 
finger,  the  tear  in  the  vaginal  wall  may  be  felt  and  traced  to  its  full  extent. 
When  its  extent  can  not  be  satisfactorily  made  out  with  the  fingers  alone,  the 
vagina  may  be  held  open  with  retractors  and  the  length  of  the  tear  ascer- 
tained by  inspection.  The  tear  may,  in  exceptional  cases,  extend  around 
the  sphincter  ani,  on  one  or  both  sides,  without  extending  through  that  mus- 
cle into  the  rectum. 

3.  There  may  be  a  tear  of  the  perineum  through  the  sphincter  ani  muscle 
into  the  rectum— laceration  of  the  "third  degree"  (Fig,  476).     This,  of  course, 


536 


RELAXATION   AND   FISTULAE 


occurs  only  in  exceptional  cases  and  is  usually  accompanied  by  one  or  more 
deep  tears  of  the  pelvic  floor. 

4.  The  perineum  may  be  torn  only  slightly  externally,  while  there  is  a 
deep  tear  inside  involving  the  vaginal  wall  and  the  deeper  structures.  Such  a 
tear  may  be  overlooked  unless  careful  exploration  is  made  after  labor. 


Fig.   475.     A    Deep    Laceration,     extending    up    each    vaginal    sulcus    and    involving    the    Pelvic     Sling     on 
each    side.       (Gilliam — Practical    Gynecology.) 


^^                  vM- 

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i 

R '  "!^^^ 

L 

^m 

B^S^"^,              ^^^^'^^'im^ 

'Wi^M 

Hk 

/^ 

^y             # 

Pfk 

^^K     V     --^<* -'-'>' 

Mm 

\ 

^^\   \  ■^^1^^^^ 

W.v/i^ 

^K     •   ^'S^t'nanK^^Wwi 

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^ 

Fig.  476.  A  Laceration  extending  directly  through  the  Sphincter  Ani  muscle  and  other  struc- 
tures between  the  vagina  and  rectum.  The  Levator  Ani  muscles  are  not  involved.  (Gilliam— Fractt- 
fa/  Gynecology.) 


RELAXATION  OP  PELVIC  FLOOR  537 

5.  The  vaginal  wall  and  perineum  may  be  torn,  the  rim  of  the  vaginal 
orifice  remaining  intact.  This  is  known  as  central  rupture  of  the  perineum 
(Fig.  218).    It  is  very  unusual. 

The  five  varieties  of  laceration  just  given  are  easily  recognized  at  the 
close  of  labor  and  should  be  repaired  at  once. 

6.  In  some  cases  the  pelvic  sling  is  seriously  damaged  without  any  open 
tear  of  the  perineum  or  vaginal  wall.  In  such  a  case  there  is  no  open  wound 
to  be  seen  or  felt.  In  fact,  in  such  a  case  it  is  difficult  or  impossible  to  make 
a  positive  diagnosis  of  laceration  at  the  time,  because  of  the  marked  stretch- 
ing and  distortion  of  the  parts  that  normally  takes  place  and  is  followed  by 
no  trouble.  In  such  a  case,  the  individual  tears  in  the  muscles  are  probably 
small  and  numerous.  The  diagnosis  is  made  later,  when  it  is  found  that  the 
pelvic  floor  is  weak  and  does  not  furnish  proper  support.  Such  cases  are,  by 
some  writers,  designated  as  ''relaxation  of  the  pelvic  floor."  But  there  is  no 
reason  why  the  term  ''relaxation"  should  be  applied  to  this  form  of  tear  any 
more  than  to  the  open  tear.  Of  course,  a  condition  of  relaxation  is  found  after 
all  severe  injuries  of  the  pelvic  floor,  but  that  simply  means  that  there  has 
been  a  tear,  either  open  or  subcutaneous,  and  the  condition  should  be  con- 
sidered under  the  head  of  laceration. 

Skene  mentions  having  seen  three  cases  of  such  subcutaneous  injury  in 
which  the  sphincter  ani  was  also  torn.  Each  patient  had  incontinence  of 
feces,  and  yet  the  most  careful  examination  failed  to  show  any  evidence  of 
an  open  tear,  either  over  the  perineum  or  in  the  vagina. 

Results  of  the  Laceration 

In  laceration  of  the  pelvic  floor,  not  repaired  at  once,  there  is  decided  in- 
crease in  the  chance  of  infection  following  labor.  If  the  patient  escapes 
sepsis,  there  is  not  much  discomfort  until  she  gets  up  and  about,  for  as  long 
as  she  is  lying  in  bed  the  loss  of  support  at  the  pelvic  outlet  is  but  little 
noticed.  Of  course,  if  the  tear  has  extended  into  the  rectum  there  is  incon- 
tinence of  feces. 

After  the  patient  has  been  up  and  about  the  house  for  a  short  time,  she 
notices  decided  weakness  in  the  pelvis,  which  becomes  more  marked  as  she 
becomes  otherwise  stronger  and  attempts  more  work.  She  complains  of  a 
dragging  weight  in  the  pelvis  and  of  backache.  As  the  uterus  sinks  in  the 
pelvis,  the  cervix  frequently  goes  forward,  as  well  as  doAvnward,  and  the  fun- 
dus goes  backward  in  retroversion.  This  tendency  of  the  cervix  to  sink  do-wn- 
ward  and  forward  is  increased  by  the  inflammation  and  subinvolution  result- 
ing from  cervical  lacerations,  received  in  the  same  labor. 

On  inspection,  it  is  found  that,  instead  of  a  normal  vaginal  opening,  the 
vaginal  outlet  is  relaxed- — that  is,  it  is  open  and  without  tone  or  resistance. 
The  two  index  fingers  introduced  into  the  opening  (Fig.  55)  may  be  carried 
to  the  sides  of  the  pubic  arch  with  but  little  resistance.    If  now  the  patient  be 


538  RELAXATION    AND   FISTULAE 

directed  to  bear  down  or  strain,  as  in  defecation,  the  sinking  and  protrusion 
of  the  parts  become  more  marked,  and  the  relaxation  of  the  floor  is  more  ap- 
parent. Another  method  of  testing  the  relaxation  of  the  floor  is  shown  in 
Figs.  53  and  54.  The  margin  of  the  untorn  portion  of  the  pelvic  sling  may 
often  be  felt  on  one  or  both  sides  in  the  vagina  some  distance  from  the  vaginal 
orifice. 

Though  in  most  cases  of  laceration,  the  vaginal  orifice  is  widened  and 
patulous  and  the  remaining  perineum  very  narrow,  in  some  cases  the  skin 
surface  of  the  perineum  is  intact  and  the  vaginal  orifice  is  small  and  placed  at 
the  normal  distance  from  the  anus.  A  superficial  examination  of  such  a  pa- 
tient would  lead  to  the  conclusion  that  the  pelvic  floor  was  intact,  but  exam- 
ination within  the  vagina  (Fig.  53)  shows  marked  relaxation,  establishing 
the  fact  of  serious  laceration  of  the  pelvic  sling. 

Subinvolution  of  the  vagina  with  more  or  less  atrophy  of  the  pelvic  mus- 
cles, results  from  unrepaired  laceration  of  the  pelvic  floor. 

Effects  of  the  Loss  of  Support 

The  cervix  sinks  into  the  pelvis  and  comes  forward  and  the  fundus  uteri 
frequently  goes  backward  into  retro  displacement  (Fig.  323).  Also,  the  whole 
uterus  lies  too  low  in  the  pelvis,  constituting  prolapse  of  the  uterus  (Fig.  268). 

As  the  damaged  pelvic  floor  and  other  supports  of  the  uterus  gradually 
stretch  more,  the  uterus  may  sink  so  low  that  the  cervix  appears  at  the  vag- 
inal opening  (Fig.  269).  As  the  uterus  sinks  lower  the  vaginal  opening  en- 
larges and  the  vaginal  walls  roll  outward,  forming  anterior  or  posterior  col- 
pocele  .(Fig.  222). 

With  the  prolapsed  posterior  vaginal  wall,  sometimes  the  anterior  wall 
of  the  rectum  is  found,  forming  a  rectocele  (Figs.  223,  224,  227,  228).  An  ap- 
pearance resembling  rectocele  may  be  produced  by  prolapse  of  a  thickened 
vaginal  wall.  There  is  areolar  hyperplasia  and  often  considerable  venous  di- 
latation, giving  quite  a  large  projecting  mass,  but  without  displacement  of  the 
anterior  rectal  wall.  AVhether  or  not  rectocele  is  really  present,  is  easily  as- 
certained by  rectal  examination,  to  determine  if  the  anterior  rectal  wall  is 
pouched  forward  with  the  vaginal  wall  (Figs.  224,  229,  230).  In  some  cases 
of  rectocele,  a  large  pouch  is  formed  and  interferes  much  with  emptying  the 
rectum,  it  being  necessary  for  the  patient  to  push  back  the  protruding  rec- 
tocele to  secure  satisfactory  bowel  movement   (Fig.  228). 

If  the  base  of  the  bladder  follows  the  prolapsing  anterior  vaginal  wall, 
the  condition  is  known  as  cystocele  (Figs.  223,  224,  225).  It  can  be  determined 
by  a  sound  or  stiff  catheter  in  the  bladder  (Fig.  226).  Sometimes  a  supposed 
cystocele  is  found  to  be  only  vaginal  wall.  In  marked  cystocele,  a  large  pouch 
is  formed  at  the  floor  of  the  bladder,  in  which  residual  urine  remains  and  de- 
composes, causing  much  bladder  irritation.  It  is  sometimes  necessary  for  the 
patient  to  push  back  the  protruding  cystocele  before  a  satisfactory  evacuation 


RELAXATION  OF  PELVIC  FLOOR  539 

of  the  bladder  can  be  secured.  Straining  at  defecation  or  urination  greatly 
aggravates  the  cystocele.  In  some  cases  both  rectocele  and  cystocele  are  pres- 
ent (Figs.  223,  224). 

"When  the  vaginal  entrance  is  relaxed,  air  can  enter  the  vagina,  and  it 
is  sometimes  expelled  with  more  or  less  noise,  which  is  very  annoying  to  the 
patient.  This  phenomenon  is  known  as  ''flatus  vaginalis."  It  is  merely  a 
symptom  of  relaxed  vaginal  orifice.  It  was  formerly  described  under  the  queer 
title  of  "garrulity  of  the  vulva." 

Laceration  of  Sphincter  Ani  Muscle 

If  the  laceration  of  the  pelvic  outlet  has  extended  through  the  sphincter 
ani  muscle,  there  will  be  incontinence  of  feces  and  intestinal  gases,  making 
the  patient  miserable  and  excluding  her  from  society.  "When  completely  torn, 
the  sphincter  ani  retracts — sometimes  to  such  an  extent  that  it  scarcely  reaches 
half  way  around  the  rectal  opening.  It  may  be  felt  as  a  thick  cord  at  the 
posterior  part  of  opening.  A  slight  dimple,  or  retraction  of  tissue,  frequently 
marks  the  location  of  each  end  (Fig.  217).  A  small  area  of  the  rectal  mucous 
membrane  may  be  visible  as  a  red  inflamed-looking  spot,  marking  the  situation 
of  the  anus  (Fig.  215,  216). 

If  the  sphincter  muscle  is  not  completely  torn,  a  few  fibers  remaining 
intact,  the  patient  may  be  able,  even  from  the  first,  to  retain  solid  feces — 
that  is,  there  is  only  partial  incontinence.  In  these  cases  of  partial  rupture 
of  the  sphincter,  and  also  in  cases  of  complete  rupture  in  which  the  muscle 
was  paralyzed  by  the  stretching  before  rupture  and  the  ends  of  the  muscles 
or  tissues  close  to  the  muscle  lay  in  contact  and  became  partially  united,  the 
patient  has  control  of  the  bowels  except  when  diarrhea  is  present.  In  some 
cases  the  patient  has  control  over  feces,  both  solid  and  liquid,  but  there  is  in- 
continence of  gases. 

In  some  of  these  cases  of  partial  incontinence,  a  wide  area  of  scar-tissue 
lies  between  the  ends  of  the  muscle.  In  such,  do  not  be  misled  into  the  be- 
lief that  there  has  not  been  a  rupture  of  the  sphincter.  The  rupture  of  the 
muscle  is  practically  complete  and  the  ends  must  be  denuded  and  united  the 
same  as  if  the  patient  had  no  control  of  the  bowels. 

A  laceration  through  the  sphincter  ani  muscle  and  recto-vaginal  septum, 
does  not  necessarily  mean  that  there  has  been  great  damage  to  the  pelvic 
sling.  The  principal  part  of  the  sling  passes  back  of  the  rectum,  not  between 
it  and  the  vagina  (Fig.  473). 

If  the  rectal  tear  is  accompanied  by  deep  lacerations  at  the  sides  of  the 
vagina,  involving  the  levator  ani  muscles,  then  there  Avill  be  marked  loss  of 
support  in  the  pelvic  floor  and  consequent  relaxation  of  the  vaginal  outlet. 
Such  accompanying  deep  lateral  lacerations  do  frequently  occur  with  the  re- 
sult mentioned.  But  in  some  cases,  the  tear  in  the  median  line  into  the  rectum 
seems  to  have  been  the  only  serious  damage.    In  such  a  case,  the  incontinence 


540  RELAXATION   AND   FISTULAE 

of  feces  is  the  only  troublesome  symptom,  there  being  no  evidence  of  want  of 
support  for  the  pelvic  organs. 

This  essential  difference  between  median  and  lateral  lacerations,  explains 
why  it  is  that  some  eases  of  complete  perineal  laceration  with  incontinence  are 
not  accompanied  with  the  prolapse  of  the  uterus  and  vaginal  walls,  so  fre- 
quently seen  in  incomplete  perineal  lacerations.  On  the  old  theory  that  the 
perineum  was  the  important  supporting  structure  at  the  pelvic  outlet,  this 
class  of  eases  was  inexplicable.  Since  the  facts  in  regard  to  the  anatomy  and 
function  of  the  component  parts  of  the  pelvic  floor  have  become  kno-\vn,  these 
cases  are  easily  explained. 

Complications 

In  old  lacerations  of  the  pelvic  floor,  there  are  frequently  present  vaginal 
discharge,  painful  menstruation,  irregular  menstruation,  excessive  menstru- 
ation, attacks  of  severe  pelvic  pain,  dyspareunia,  sterility,  abortion,  various 
reflex  phenomena  and  general  poor  health.  These  symptoms  however  are  due 
principally  to  associated  diseases,  some  of  which  may  be  traced  to  the  lacer- 
ation. The  diseases  which  are  frequently  associated  with  laceration  of  the 
pelvic  floor  are : 

Laceration  of  cervix. 
Chronic  endometritis. 
Subinvolution. 

Retrodisplacement  of  uterus. 
Prolapsus  uteri. 
Chronic  salpingitis. 

All  lesions  present  should  be  found  and  their  severity  determined  before 
operative  treatment  is  undertaken. 

Treatment 

In  a  fresh  laceration  of  the  pelvic  floor  or  perineum  in  labor,  the  rule  is  to 
repair  the  injury  at  once.  Even  though  the  tear  is  not  deep  enough  to  dam- 
age, the  pelvic  floor,  it  should  be  repaired,  for  every  laceration  closed  lessens 
to  that  extent  the  chance  of  infection.  For  the  same  reason,  tears  of  the  an- 
terior vaginal  wall  or  of  the  vulva  should  be  repaired  at  once.  The  details 
of  this  immediate  repair  belong  to  obstetric  work,  and  need  not  be  consid- 
ered here. 

In  an  old  laceration  repair  of  the  pelvic  floor,  months  or  years  after  the 
injury,  is  a  much  more  tedious  operation  and  requires  more  preparation  and 
skill.  The  parts  have  been  stretched  out  of  their  normal  relations  and  the 
contraction  of  the  scar-tissue  has  drawn  mucous  membrane  over  the  damaged 
areas. 

Palliative  Measures.  In  a  ease  of  old  laceration,  waiting  for  operation  or 
in  which  operation  is  not  advisable,  considerably  temporary  relief  may  be 


TREATMENT  OF  RELAXATION  OF  PELVIC  FLOOR  '  541 

afforded  by  the  knee-chest  posture,  takeii  for  a  few  minutes  morning  and  eve- 
ning. In  some  cases  the  patient  is  made  more  comfortable  by  some  one  of  the 
pessaries  useful  in  retrodisplacement  or  prolapse  (see  pages  371  to  390).  Vag- 
inal tamponade  also  gives  some  temporary  relief.  Astringent  douches,  rest 
in  the  recumbent  posture  several  times  daily,  and  the  various  means  for  re- 
ducing pelvic  congestion  are  useful  palliative  measures. 

Operative  Treatment.  For  permanent  relief,  operation  is  necessary.  Many 
operative  procedures  have  been  designed,  the  principal  ones  of  which  are 
mentioned  below. 

Object  of  the  Operation 

The  object  of  the  operation  is  to  restore  a  strong  sling  across  the  pelvic 
outlet  to  support  the  organs  above.  To  restore  the  integrity  of  the  pelvic 
floor,  the  following  two  things  must  be  accomplished : 

1.  The  musculo-fibrous  pelvic  sling  must  be  shortened  so  that  the  slack 
is  taken  up. 

2.  The  vaginal  opening  (the  necessarily  weak  place  in  the  pelvic  floor) 
must  be  brought  forward  under  the  pubic  arch  and,  consequently,  out  of  the 
line  of  direct  pressure  from  above. 

Repairing  the  perineum  is  known  as  "perineorrhaphy,"  Suturing  the 
vaginal  wall  is  designated  as  "  colporrhaphy. " 

Though  the  literal  meaning  of  each  of  these  terms  is  limited,  they  are 
by  common  consent  used  to  indicate  the  general  suturing  usually  necessary 
in  these  cases.  A  more  accurate  and  comprehensive  designation  for  this  oper- 
ation is  ** repair  of  the  pelvic  floor."  This  operation  comes  under  the  general 
class  known  as  "plastic  operations,"  which  includes  also  repair  of  cervix, 
operation  for  cystocele  and  closure  of  fistulae. 

Indications  and  Contraindications 

The  indications  for  repair  of  the  pelvic  floor  are : 

1.  Decided  symptoms  of  loss  of  support  at  the  pelvic  outlet — such  as 
dragging  weight  in  the  pelvis,  backache  and  a  feeling  of  weakness  there. 

2.  Prolapse  of  the  vaginal  walls,  with  or  without  cystocele  or  rectoeele. 

3.  Prolapse  of  the  uterus. 

4.  Movable  retrodisplacement  in  which  a  pessary  cannot  be  retained,  on 
account  of  the  laceration  at  the  vaginal  outlet. 

5.  Incontinence  of  feces,  indicating  damage  to  the  sphincter  ani. 
The  contraindications  are: 

1.  Absence  of  decided  symptoms  of  loss  of  support  in  the  pelvic  floor. 

2.  Marked  kidney  lesion  or  other  serious  disease  contraindicating  anes- 
thesia. 

3.  Hemophilia.  Skene  encountered  three  such  patients.  -Two  of  them 
were  operated  on  before  the  bleeding  tendency  was  discovered,  the  result  be- 


542  EELAXATION    AND   FISTULAE 

ing  failure  of  the  operation  in  each  ease  and,  as  he  remarks,  ''the  develop- 
ment of  extreme  caution  on  the  part  of  the  operator  in  selecting  cases  in  the 
future."  In  the  third  case,  the  fact  that  the  patient  was  a  ''bleeder"  was 
elicited  in  getting  the  history,  and  consequently  the  operation  was  not  ad- 
vised. 

4.  Uterine  disease  with  an  infectious  discharge.  The  uterine  disease 
should  be  treated  and  the  infectious  discharge  checked  before  any  plastic 
operation  is  undertaken. 

Preparations  for  the  Operation 

The  preparations  for  repair  of  the  pelvic  floor  may  be  divided  into  (1) 
preparation  of  the  patient,  (2)  preparation  of  the  instruments  and  dressings 
and   (3)  preparation  of  the  operator  and  assistants. 

1.  Preparation  of  the  Patient.  The  general  preparations  as  for  any  oper- 
ation requiring  an  anesthetic,  are  carried  out  (see  preliminary  preparation  of 
patient  for  Abdominal  Section,  Chapter  xvi). 

It  is  well  to  time  the  operation  so  that  the  healing  surfaces  will  not  be  dis- 
turbed by  the  menstrual  flow  for  ten  days  or  two  weeks  after  operation.  Con- 
sequently, the  preferable  time  for  the  operation  is  from  three  to  ten  days  af- 
ter menstruation.  The  antiseptic  preparation  of  the  patient  in  this  particu- 
lar operation  is  confined  to  the  vagina  and  adjacent  regions.  The  patient 
should  receive  an  antiseptic  douche  once  or  twice  daily  up  to  the  time  of 
operation.  Several  hours  before  operation  or  the  day  before,  the  field  of 
operation  should  be  shaved.  The  shaving  includes  the  pubic  and  perineal  re- 
gions and  the  adjacent  portions  of  the  thighs  and  buttocks.  The  surfaces  are 
then  washed  with  green  soap  and  warm  water  with  a  soft  brush  or  cotton- 
balls.  The  soap  is  then  washed  off  with  sterile  water  and  the  surfaces  are 
washed  with  bichloride  solution  (1-2000).  The  surfaces  are  then  dried  with 
a  sterile  towel  or  cotton-balls  and  covered  with  a  large  piece  of  cotton  wrung 
out  of  bichloride  solution  (1-5000). 

After  the  patient  is  under  the  anesthetic,  the  vagina  is  scrubbed  thor- 
oughly with  warm  soap-solution,  using  cotton-balls  held  in  long  forceps.  Two 
fingers  of  the  left  hand  are  introduced  into  the  vagina  and  all  portions  of  the 
vaginal  walls  are  put  on  the  stretch  as  they  are  scrubbed  (Figs.  560,  561).  A 
brush  is  too  harsh  for  the  purpose  and  it  can  not  be  handled  as  satisfactorily 
as  the  cotton  in  the  forceps.  The  external  genitals  and  the  entire  field  of 
operation  is  again  scrubbed  with  the  soap-solution.  The  soap  is  then  washed 
off  with  sterile  water,  and  the  vagina  and  external  surfaces  are  scrubbed  with 
bichloride  solution  (1-2000).  The  sterile  cloths  are  then  placed  about  the  field 
and  the  patient  is  ready  for  operation. 

2.  Preparation  of  Instruments  and  Dressings.  The  details  of  the  antisep- 
tic preparation  of  the  instruments  and  dressings  are  given  under  Preparations 
for  Abdominal  Section,  in  Chapter  xvi). 


TREATMENT    OF    RELAXATION    OF   PELVIC   FLOOR  543 

The  instruments  required  for  repair  of  the  pelvic  floor  are  sho^^^l  in  Fig. 
477. 

There  should  be  at  hand  also : 

Leg  holders,  in  the  form  of  uprights  attached  to  the  table  (Fig. 

558). 
Perineal  pad. 
Fountain  syringe. 
Rubber  apron  for  operator. 
Gowns  for  operator  and  assistants. 


Fig.  477.  Instruments  for  Repair  of  the  Pelvic  Floor:  a,  short,  tenaculum  forceps  (have^our) ; 
b,  bistoury;  c,  long  tissue  forceps;  d,  long  scissors  for  denuding;  e,  vaginal  dressing  forceps  for 
sponging  (have  two) ;  f,  hemostat  forceps  for  holding  suture  ends  or  catching  bleeding  points  (have 
eight);  g,  right-angled  vaginal  retractor  (have  two);  h,  short  scissors  for  cutting  suture  material; 
i,  Sims'  needle-holder;  j,  number  2,  20-day  catgut  (have  six  tubes)  and  strong  full-curved  round- 
point  needles  (have  four)  ;  k,  silkvk'orm-gut  (have  eight  strands)  and  large  full-curved  Hagedorn 
needles    (have   four).      The    large  needles   may   be   used  without   a   needle-holder. 

For  the  anesthetist  there  should  be : 

Ether-inhaler  and  chloroform-inhaler. 
Ether  and  chloroform. 
Tongue  and  forceps. 
Vaseline,  for  patient's  face. 
Hypodermic  syringe. 
Necessary  stimulants. 

3.  Preparation  of  Operator  and  Assistants.  The  antiseptic  and  aseptic 
preparation  for  the  operator  and  assistants  for  operative  work  in  general,  is 
given  in  detail  under  Preparations  for  Abdominal  Section   (Chapter  xvr). 

Two  assistants,  beside  the  anesthetist,  are  needed  for  rapid  work,  one  to 


544 


RELAXATION    AND   FISTULAE 


expose  the  various  portions  of  the  field  of  operation  and  the  other  to  sponge 
away  the  blood  and  handle  sutures.  A  good  nurse  does  well  as  one  of  these 
assistants. 

OPERATIVE  METHODS 

The  treatment  of  relaxation  of  the  pelvic  floor  consists  in  taking  up  the 
slack,  so  that  the  pelvic  sling  is  sufficiently  shortened,  and  in  restoring  the 
perineal  body,  so  as  to  carry  the  weak  place  in  the  pelvic  floor  (the  vaginal 
opening)  forward,  out  of  the  line  of  direct  pressure. 


A  B 

Fig.  478.  Recent  Lacerations  in  Labor.  A.  Laceration  involving  the  perineum  and  extend- 
ing up  tlie  right  vaginal  sulcus.  B.  More  severe  Laceration,  involving  the  perineum  and  extending 
up   both  vaginal   sulci.      (Dickinson — American   Textbook  of  Obstetrics.) 

The  pelvic  sling,  the  strong  supporting  part  of  the  pelvic  floor,  consists 
of  the  levator  ani  muscles  and  the  fascia  above  and  below  (Fig.  467).  This 
musculo-fibrous  sling  or  diaphragm  is  the  structure  worked  upon  in  repair 
of  the  pelvic  floor.  Shortening  of  this  sling  restores  the  pelvic  floor  support, 
while  if  there  is  no  shortening  of  the  sling,  there  is  no  lasting  restoration  of 
support. 

As  operative  treatment  for  this  condition  deals  principally  with  one  struc- 
ture (the  pelvic  sling),  there  is  not  the  confusing  multiplicity  of  radically  dif- 
ferent operations  found  in  the  treatment  of  uterine  retrodisplacement  and 


OPERATIVE  TREATMENT  545 

prolapse,  where  many  different  structures  may  be  utilized  for  support.  For 
restoration  of  the  pelvic  floor  there  is  just  one  modern  operation  and  its  es- 
sentials are  (a)  exposure  of  the  museulo-fibrous  sling  by  incision  through  cov- 
ering mucosa  or  skin,  (b)  shortening  of  the  sling  and  coaptation  of  the  peri- 
neal tissues,  and  (e)  closure  of  the  wound  in  the  superficial  tissues.  The  in- 
cision through  the  vaginal  mucosa  of  perineal  skin  is  simply  to  allow  access 
to  the  deeper  and  more  important  structures.  It  corresponds  to  the  incision 
through  the  abdominal  wall  in  abdominal  work.  The  pelvic  floor  is  "opened" 
to  allow  access  to  the  real  supporting  structures,  and  when  they  are  repaired 
the  opening  is  closed. 

There  are  variations  of  teehnic  in  the  different  steps,  particularly  in  the 
opening  and  closing.  The  methods  of  opening  and  closing  the  pelvic  floor  dif- 
fer so  much  that  one  may  be  inclined,  on  first  thought,  to  class  them  as  radi- 
cally different  operations.  A  closer  study,  however,  will  show  that  the  really 
important  feature,  the  approximation  of  the  muscles  and  fascia  between  the 
vagina  and  rectum,  remains  practically  the  same.  Also,  there  are  slight  vari- 
ations in  suturing  and  in  approximation  of  the  deep  tissues,  but  these  are 
only  minor  differences.  For  a  time  a  radically  different  method  of  shorten- 
ing the  levator  sling  was  in  use.  This  consisted  in  excising  a  portion  of  the 
sling  on  one  or  both  sides  and  approximating  the  cut  edges.  This  proved 
useful,  for  it  demonstrated  and  emphasized  that  the  shortening  of  the  sling 
was  the  important  thing.  It  was  found,  however,  that  the  necessary  short- 
ening could  be  more  easily  and  more  effectively  accomplished  by  subvaginal 
approximation  of  the  sides  of  the  museulo-fibrous  sling.  This  is  a  physiologic 
but  not  an  anatomic  restoration  of  the  pelvic  floor.  In  fact,  anatomically  it 
is  a  marked  distortion  of  the  parts,  in  that  it  throws  the  main  supporting 
sling  between  the  vagina  and  rectum  instead  of  back  of  the  rectum  as  it  is 
normally.  Much  energy  and  good  paper  have  been  Ivasted  in  arguing  for  a 
perfect  "anatomic"  restoration  of  the  pelvic  floor — that  is,  a  restoration  ex- 
actly "as  Nature  made  it."  The  operation,  under  consideration  has  been 
lauded  as  such,  but  it  is  not.  However,  it  gives  support,  relieves  the  symp- 
toms and  enables  the  patient  to  pursue  her  activities  in  comfort,  which,  after 
all,  is  the  ultimate  result  sought. 

This  effective  and  satisfactory  operation  was  not  completed  by  the  originator. 
It  was  of  slow  growth,  and  reached  its  present  perfection  through  the  pioneer 
work  of  many  men  through  many  decades.  In  the  fifty  years  prior  to  1880, 
much  work  was  done  in  repair  of  the  pelvic  floor,  but  it  was  practically  con- 
flned  to  excision  of  portions  of  the  vaginal  mucosa  and  suturing  of  the  result- 
ing wounds.  Emmet,  in  his  epochal  work  in  the  early  eighties,  pointed  out 
the  necessity  ^.f  reaching  and  uniting  the  deeper  structures  of  the  pelvic  floor. 
His  "butterfly"  denudation  exposed  the  injured  area  in  each  lateral  sulcus, 
and  he  insisted  that  the  sutures  be  passed  so  as  to  include  the  deep  tissues 
of  the  sides  of  the  sulcus.     The  importance  of  this  point  was  partly  obscured 


546  RELAXATIOX    AXD    FISTULAE 

by  the  emphasis  placecl  on  the  form  of  denudation,  which  seemed  to  fill  the 
eye  .of  operators.  Much  ingenuity  was  displayed  in  devising  forms  of 
denudation.  Later  it  came  to  be  recognized  that  it  was  not  the  form  of 
denudation  but  the  inclusion  of  the  deeper  tissues  in  the  sutures  that  deter- 
mined the  permanency  of  the  result.  Soon  it  was  appreciated  that  the  best  re- 
sult was  secured  by  a  definite  shortening  of  the  levator  ani  muscles  with  the 
associated  fasciae.  There  were  two  methods  of  shortening  this  musculo-fibrous 
sling.  It  could  be  shortened  by  the  lateral  excision  or  folding,  or  by  approxi- 
mation of  the  two  sides  of  the  sling  between  the  vagina  and  the  rectum. 
Various  methods  were  proposed  for  exposing  the  sling  and  for  shortening  the 
same,  and  ''new"  operations  for  restoration  of  the  pelvic  floor  appeared  in 
great  number.  Eeduced  to  essentials,  however,  each  new  operation  fell  into 
one  or  the  other  of  the  two  classes  mentioned — that  is,  the  sling  was  short- 
ened by  lateral  excision  or  folding  or  it  was  shortened  by  median  approxi- 
mation between  the  vagina  and  the  rectum.  After  prolonged  trial  it  was  es- 
tablished that  the  latter  method  was  the  preferable  one.  This  accomplishes 
the  desired  object  most  effectively  and  in  the  simplest  way.  Consequently 
the  other  method  (lateral  excision  or  folding)  has  dropped  out  of  use,  and 
may  now  be  classed  among  the  "former  operations." 

Subvaginal  approximation  of  the  sides  of  the  pelvic  sling  remains,  then, 
the  one  advisable  operation  for  repair  of  the  pelvic  floor.  Among  different 
operators  there  are  decided  differences  in  regard  to  minor  details,  as  previ- 
ously explamed.  But  the  essential  features  are  generally  recognized  and 
usually  followed. 

As  to  whom  credit  is  due  for  the  various  steps  in  the  development  of 
this  operation,  a  full  exposition  of  that  would  require  a  detailed  historical 
review  of  such  length  as  to  be  out  of  place  here.  The  primary  impetus  to 
the  inclusion  of  deep  tissue  came  principally  from  the  splendid  work  of  Em- 
met. In  later  pioneer  work.  Hegar  and  Tait  were  prominent.  The  Tait 
method  of  denudation  by  raising  a  flap  (so-called  flap-splitting)  is,  with  modi- 
fications, the  method  now  most  generally  employed  for  opening  the  pelvic 
floor.  *•■    ; 

The  later  work  with  the  deep  structures  developed  gradually  as  the  result 
of  suggestions  by  a  large  number  of  operators,  each  contributing  somewhat 
to  the  general  advance.  The  perfected  operation  is  not  due  to  any  one  per- 
son but  to  many,  and  the  author  hesitates  to  single  out  individuals  on  ac- 
count of  possible  injustice  to  those  not  mentioned.  However,  it  may  be  stated 
that  as  far  as  the  author  has  noted,  shortening  of  the  musculo-fibrous  sling 
by  definite  exposure  and  excision  laterally,  was  first  described  by  Harris  in 
1897.  (Jour.  A.  M.  A.).  In  the  same  year  a  method  of  subvaginal  approxi- 
mation of  the  sides  of  the  sling  was  described  by  Noble  (Am.  Gynec.  and 
Obstet.  Jour.).  fSinee  then  the  technic  has  been  perfected  by  useful  sug- 
gestions from  manv  contril)utors. 


TECHNIC    OF    OPERATION 


547 


TECHXIC  OF  OPERATION 

The  various  phases  of  technic  ^vill  be  presented  in  the  following  order: 

Eegular  oijeration,  according  to  the  technic  considered  by  the  author 

most  satisfactory. 
Variations  in  technic. 
Laceration  through  the  sphincter  ani. 

Steps  in  Regular  Operation 

1.  Planning  tlie  Restored  Vaginal  Opening.    By  careful  examination  of  the 
vaginal  entrance,  the  opening  of  the  duct  of  the  vulvo-vaginal  gland  may  be 


Fig.  479.     The    edge    of    the    vaginal    flap    is    freed 
with   a   knife. 


Fig.  480.  Next  the  underlying  tissues  are  pushed 
off  with  the  gauze-covered  finger  from  the  vaginal 
wall  which  is  held  tightly  stretched  over  the  index 
finger  of  the  left  hand  by  means  of  a  forceps. 


identified  on  each  side.  Just  below  this  on  each  side  the  tissue  should  be 
caught  firmly  with  the  tenaculum  forceps  or  other  holder.  To  determine  if 
repair  to  this  point  vnll  leave  a  vaginal  opening  of  proper  size,  the  forceps 
may  be  crossed  and  the  sides  brought  together. 

Care  should  be  taken  to  keep  sutures  and  scar-tissue  from  the  immediate 
vicinity  of  the  vulvo-vaginal  glands.  If  this  duct  on  either  side  is  included 
in  the  operation  area,  it  is  likely  to  give  rise  to  a  hypersensitive  and  trouble- 
some scar  and  may  result  in  definite  cyst  formation. 

2.  Opening  the  pelvic  floor.  The  incision  extends  from  one  forceps  to  the 
other  (Fig.  479).  It  should  be  placed  well  within  the  vagina.  When  so  placed 
it  is  farther  removed  from  the  rectum,  and  hence  from  infection,  and  is  in 
tissue  less  sensitive  than  the  perineal  skin.     If  preferred,  the  line  of  tissue 


548 


RELAXATION    AND   FISTULAE 


may  be  made  tense  and  then  clipped  off  with  the  scissors,  or  the  tense  line 
of  tissue  may  be  excised  with  a  knife. 

After  the  incision  is  made,  the  margin  of  the  flap  is  bared  by  knife  or 
scissors,  as  indicated  in  Fig.  479,  and  then  caught  with  a  forceps.  With  the 
gauze-covered  finger  the  underlying  tissues  are  quickly  rolled  off  the  vaginal 
flap  sufficiently  to  expose  the  deep  musculo-fibrous  sling  (Fig.  480).  The 
same  step  is  then  carried  out  on  the  other  side.  In  this  separation  of  the  tis- 
sues from  the  vaginal  flap,  if  there  is  much  scar -tissue  it  may  be  necessary 
to  divide  it  at  some  points  with  the  knife  or  scissors. 

Care  must,  of  course,  be  exercised,  to  avoid  opening  into  the  rectum.  The 
layer  of  veins  constitutes  the  guide  to  safety.  So  long  as  the  line  of  cleav- 
age is  kept  between  these  veins  and  the  vaginal  wall,  the  rectum  is  safe.  On 
the  other  hand,  when  the  veins  are  permitted  to  remain  on  the  vaginal  flap. 


Fig.   481.       The    musculo-fibrous    sling    is    caught  Fig.   482.      Sling  lifted  out  with  forceps  on  either 

with    a    forceps    and    brought    out    for    identification        side.     First  appro.ximation  suture  passed,  making  two 
and  to  permit  more  accurate  placing  of  the  sutures.         rounds   with   suture   before   tying. 


the  line  of  cleaA^age  is  going  too  deeply  and  a  hole  may  be  torn  into  the  rec- 
tum at  any  time. 

3.  Identification  and  isolation  of  the  musculo-fidrous  sling.  "When  the 
vaginal  flap  is  raised  sufficiently,  the  smooth  surface  of  the  sling  may  be  seen 
(Fig.  21).  When  exposed  on  both  sides,  the  sutures  may  be  passed  through 
the  tissues  in  that  situation  under  the  guidance  of  the  finger.  The  author 
prefers,  however,  to  catch  the  sling  on  each  side,  in  a  tenaculum  forceps  and 
draw  it  well  into  view,  as  shown  in  Figs.  481  and  482.  By  this  means  the 
tissues  are  more  positively  identified  as  part  of  the  pelvic  sling  and  the  su- 
tures may  be  placed  more  accurately. 

4.  Approximating  the  sides  of  the  sling.  The  exposed  sides  of  the  sling  are 
fastened  securely  together  by  sutures,  as  indicated  in  Figs.  482  and  483.  It 
is  well  to  pass  the  suture  twice,  so  that  there  is  a  double  suture  or  two  rounds 
to  each  knot,  each  round  of  the  suture  including  a  somcAvhat  different  por- 


TECHNIC    OF    OPERATION 


549 


tioii  of  the  pelvic  sliiig.  Too  many  knots  increase  the  chances  of  irritation 
and  suppuration.  When  one  suture  has  been  passed  and  tied,  it  may  be  left 
long  to  serve  as  a  tractor  (Fig.  483)  and  the  tenaculum  forceps  may  then 
be  removed. 

The  sutures  should  not  be  too  tight.  There  will  be  considerable  repar- 
ative swelling  of  the  tissues,  and  if  the  tissues  included  in  the  sutures  are 
firmly  constricted  to  start  with,  there  may  be  sloughing.  The  sides  of  the 
niusculo-fibrous  sling  should  be  approximated  over  a  broad  area,  so  as  to  se- 
cure a  firm,  broad  union.  Two  or  three  sling  sutures  are  usually  sufficient. 
Before  placing  other  sutures,  let  the  flap  drop  and  test  the  size  of  the  vag- 
inal opening  by  introducing  three  fingers.  At  this  stage  of  the  operation 
the  opening,  should  admit  three  fingers  easily.  It  is  narrowed  considerably 
by  the  further  steps  of  the  operation  and  by  the  subsequent  scar  contraction, 


Fig.  483.  The  last  suture  placed  and  tied  is  left 
long  to  serve  as  tractor  after  forceps  have  been 
removed. 


Fig.  484.  The  approximation  of  the  sides  of  the 
sling  having  been  accomplished,  the  more  super- 
ficial tissues  of  the  perineum  are  united  by  inter- 
rupted sutures. 


and  if  smaller  than  three  fingers  at  this  time,  it  is  likely  to  cause  trouble  in 
coitus. 

Having  completed  the  approximation  of  the  sides  of  the  sling,  the  more 
superficial  tissues  of  the  perineum  are  united  by  sutures  as  desired  (Fig. 
484). 

5.  Closing  the  opening  in  the  pelvic  floor.  The  excess  of  vaginal  wall  is 
trimmed  aAvay,  as  shown  in  Fig.  485,  and  the  vaginal  wound  is  closed  as  in- 
dicated in  Figs.  485  and  486.  If  the  excess  of  vaginal  wall  is  not  trimmed 
away,  it  is  likely  to  form  tags  and  irregularities  which  may  prove  trouble- 
some afterward.  The  suture  which  closes  the  upper  angle  of  the  vaginal  flap 
should  take  hold  also  of  the  deeper  tissues,  in  order  to  fasten  down  this  re- 
dundant area  of  vaginal  wall. 

It  is  well  to  lock  the  running  suture  at  intervals.    If  preferred,  clips  may 


550 


RELAXATION    AND   FISTULAS 


be  used,  to  close  the  outer  portion  of  the  wound.  For  suture  material,  40- 
day  catgut  No.  1  is  very  satisfactory  throughout,  for  both  deep  and.  superficial 
sutures.  If  catgut  chromicized  for  less  than  twenty  clays  is  used,  tension  su- 
tures of  silkworm-gut  should  also  be  employed. 

Variations  in  Technic 

Another  method  of  separating  the  vaginal  flap.  Some  operators  prefer  to 
raise  the  flap  by  blunt  dissection  with  scissors  thrust  under  the  vaginal  wall. 
Injury  to  the  rectum  is  more  likely  to  occur  with  this  method  than  where  the 
parts  are  laid  open  and  the  separation  is  made  under  the  guidance  of  the  eye. 

Opening  the  pelvic  floor  hy  a  vertical  incision  (Hill).  A  vertical  incision  is 
made,  extending  to  near  the  anus.     Through  this  incision  the  sides  of  the 


Fig.  483. 


The    excess    tissue    of    the    vaginal    flap    is 
excised. 


Fig.   486.     The  vaginal  and  perineal  wound  is  closed 
with    a    continuous    catgut    suture. 


pehdc  sling  are  exposed  by  dissection  with  scissors.  Then  the  prominent  rectal 
wall  is  pushed  back  and,  under  the  guidance  of  the  fingers,  sutures  are  passed 
into  the  sides  of  the  sling,  and  the  sides  of  the  sling  are  approximated  in  the  me- 
dian line.  Particular  attention  is  given  by  Dr.  Hill  to  the  separate  approxi- 
mation of  the  superficial  perineal  structures.  The  operation  is  completed  by 
the  closure  of  the  perineal  incision. 

Opening  the  pelvic  floor  hy  a  low  transverse  incision  (Dorsett).  A  transverse 
incision  is  made  a  short  distance  above  the  anus.  Through  this  the  sides  of 
the  musculo-fibrous  sling  are  exposed  and  brought  together  in  the  median  line 
by  buried  sutures.  The  transverse  perineal  wound  is  then  pulled  apart  in 
such  a  way  as  to  make  its  long  axis  vertical.  The  wound  is  then  closed  from 
side  to  side,  leaving  a  vertical  line  of  union. 

Excision  of  mucosa  over  a  triangular  area.  This  is  the  Hegar  method  of 
denudation  so  long  in  use.  The  area  is  outlined  with  a  knife,  as  shoAAii  in  Fig. 
488.     The  tissue  is  then  removed  in  strips  by  scissors.     The  strip  to  be  re- 


TECHNIC    OF    OPERATION 


551 


moved  is  grasped  with  the  tissue  forceps  and  drawn  so  as  to  form  a  line  of 
tension,  which  line  of  tense  mucosa  is  then  excised  with  the  scissors,  as  shown 
in  Fig.  489. 

Through  the  large  opening  thus  made  the  levator  muscles,  with  their  fas- 
ciae, are  isolated  and  approximated  by  sutures,  as  schematically  indicated  in 
Fig.  490.  The  more  superficial  tissues  are  then  approximated  and  the  wound 
closed,  as  indicated  for  the  regular  operation  in  Fig.  486. 

Levator-approximation  dy  figure-of-eight  sutures.  For  these  sutures  it  is 
customary  to  use  silkworm-gut.  They  are  passed  as  follows:  Through  the 
skin  to  the  patient's  left  side,  through  the  sling  on  the  left  side,  through 
the  sling  on  the  right  side,  then  back  through  the  sling  on  the  left  side,  then 


Fig.   487.     An   old   Laceration   of  the  Pelvic   Floor,   involving  both  vaginal   sulci,      a.   The  prominent  part   of 
the    projecting    posterior   vaginal    wall.      (Penrose — Diseases    of    Women.) 


through  the  sling  on  the  right  side  again,  and  then  out  through  the  skin  on 
the  right  side.  When  such  sutures  are  tied,  they  approximate  both  the  deep 
tissues  and  the  superficial  wound,  and  there  are  no  knots  or  buried  sutures 
left  in  the  wound. 

Holden  uses  chromic  catgut  for  his  figure-of-eight  sutures,  and  passes 
them  from  the  vaginal  surface.  Tracing  each  suture,  it  passes  through  the 
mucosa  on  the  patient's  left  side,  then  through  the  right  side  of  the  sling, 
then  through  the  left  side  of  the  sling  and  then  out  through  the  vaginal 
mucosa  on  the  right  side. 


552 


RELAXATION"   AND   FISTULAE 


Emmet  method  of  denudation  (Fig.  489).  This  is  given  principally  because 
of  its  historical  importance.  It  is  not  so  satisfactory  for  the  present-day  oper- 
ation on  the  deep  structures  as  are  other  methods  of  opening  the  pelvic  floor. 
When  first  used  it  was  a  great  step  in  advance.  It  was  also  a  very  satis- 
factory method  of  opening  the  pelvic  floor  for  shortening  of  the  pelvic  sling 
by  lateral  excision  or  by  lateral  folding.  This,  however,  has  now  been  super- 
seded by  subvaginal  approximation  of  the  sides  of  the  sling  in  the  median 
line,  and  consequently  the  "butterfly"  denudation  is  passing  out  of  use. 

Steps  in  Repair  of  Lacerated  Sphincter  Ani 

When  the  sphincter  ani  muscle  has  been  torn  through  completely,  the 
ends  gradually  separate  more  and  more  until,  after  some  years,  they  are 


Fig.  488.  Emmet's  Operation,  showing  the  Lines 
of  Tension  at  each  side  of  the  left  vaginal  sulcus 
and  their  point  of  meeting  at  b.  (Penrose — Diseases 
of   Women.) 


Fig.  489.  Emmet's  Operation,  showing  the  Meth- 
od of  Denuding  the  damaged  area  in  the  left  vaginal 
sulcus.      (Penrose — Diseases  of   Women.) 


found  widely  separated,  as  shown  in  Fig.  491.  This  separation  of  the  ends 
is  due  to  contraction  and  retraction  of  the  torn  muscle,  which  straightens  out 
and  at  the  same  time  becomes  shrunken  and  atrophic.  At  operation,  this 
shortened  sphincter  muscle  must  be  stretched  in  order  to  complete  the  circle 
of  the  anus.  Also,  in  very  long-standing  cases,  the  muscular  tissue  may  be  so 
atrophic  that  it  must  be  strengthened  by  exercise  for  several  weeks  or  months 


J"        "  3 

C  d  i^  D 

Fig.    490.      The    General    Scheme    for    Suturing    in   the    Emmet    Operation. 

A.  The  inside  sutures  passed,  but  not  yet  tied.  These  sutures  may  be  interrupted  or  continuous, 
or  if  preferred,  the  deeper  parts  of  the  wounds  may  be  approximated  by  buried  sutures.  The  course  of 
the    "crown    suture"    is    here    indicated,    but    it    is    usually   not   passed    until    later. 

B.  The  inside  sutures  tied  and  the  outside  sutures  passed,  including  the  crown  suture.  The 
"crown  suture"  brings  together  the  points  r,  a,   c.     It  is  usually  passed  last. 

C.  The  outside  sutures  tied,  except  the  crown  suture.  The  tying  of  the  crown  suture  completes 
the   approximation. 

D.  The  additional  sutures  required  when  the  tear  extends  into  the  rectum.  The  rent  in  the  rectal 
wall  is  closed  by  sutures  Nos.  1,  2  and  3.  These  are  passed  from  the  rectal  surface  and  may  be  of 
catgut  or  fine  silk.  Suture  No.  4  is  passed  from  the  skin  surface.  It  is  a  strong  suture  of  silkworm-gut 
and  approximates  the  ends  of  the  sphincter  ani  muscle  and  also  the  tissues  above  the  rectal  tear  along 
its  whole  length.  Care  should  be  taken  in  passing  it  to  catch  the  retracted  sphincter  ends  and  also  the 
tissues  all  the  way  to  above  the  apex  of  the  rectal  tear,  as  here  indicated.  Before  this  suture  is  tied, 
the  torn  and  retracted  ends  of  the  sphincter  ani  muscle  should  be  brought  together  by  one  or  two  buried 
cutgut   sutures.  , 

553 


554 


RELAXATION   AND   FISTULAE 


after  repair,  before  complete  fecal  control  is  established.  Another  effect  of 
this  straightening  out  of  the  sphincter  is  that  the  point  or  upper  angle  of 
the  tear  in  the  recto-vaginal  septum  is  drawn  down  and  the  scar  approaches  a 
straight  line  (Fig.  491).  The  small  red  area^  so  frequently  seen  in  these 
cases,  and  giving  the  impression  of  granulation  tissue,  is  rectal  mucosa  ex- 
posed by  the  tear.     The  steps  in  repair  of  the  torn  sphincter  are  as  follows: 

1.  Stretching  the  shrunken  sphincter.  It  is  advisable  to  stretch  the  short- 
ened sphincter  muscle  so  that  it  may  encircle  the  anal  opening  again  without 
undue  tension.  The  moderate  lengthening  of  the  muscle  required  is  easily  ac- 
complished by  grasping  it  with  gloved  fingers  on  either  side  and  stretching  it. 

2.  Opening  the  pelvic  floor.  In  such  a  case,  the  pelvic  floor  is  opened  as 
shown  in  Fig.  491, 

Ristine  (American  Journal  of  Obstetrics,  1899,)  first  suggested  an 
''apron"  flap,  an  operation  which  has  been  further  elaborated  by  Watkins 


Fig.  491.  In  repair  of  complete  laceration,  the 
incision  is  made  about  a  half  inch  above  the  anal 
edge  (Ristine,  Watkins)  well  within  the  vagina  so 
that  no  suture  has  to  be  placed  either  into  the  rectal 
wall  itself  or  in  close  contact  with  the  anus.  A  flap 
is   dissected   off,   both   upward   and   downward. 


Fig.  492.  The  ends  of  torn  sphincter,  visible  as 
dimples  on  either  side  (Fig.  491)  are  dissected  out, 
grasped  with  forceps,  and  united  by  means  of  a  cat- 
gut suture  passed  in  two  rounds. 


(Surgery,  Gynecology  and  Obstetrics,  1908).  By  placing  the  incision  for  the 
flap  well  within  the  vagina,  from  one-half  to  one  inch  above  the  edge,  two 
sources  of  infection,  which  so  often  annihilate  the  result  of  the  most  care- 
fully performed  repair,  are  eliminated.  There  will  be  no  sutures  required 
in  the  rectal  wall,  itself,  and  the  lowest  perineal  suture,  closing  the  skin,  will 
be  far  enough  from  the  anal  opening  to  guard  against  contamination  with 
fecal  matter. 

The  flap  is  undermined  both  in  an  upward  and  downward  direction  ex- 
actly in  the  manner  described  for  the  regular  repair  of  the  incomplete  lacer- 
ation (Fig.  480).     Downwards  the  flap  is  freed  until  on  either  side  the  end 


AFTER-TREATMENT 


555 


of  the  torn  retracted  sphincter  muscle  is  reached,  Avhich  is  recognizable  on 
the  skin  surface  in  shape  of  a  little  dimple  (Fig.  491). 

S.  Suturing  the  sphincter  ani.  The  sphincter  ends  are  dissected  out,  caught 
A\'ith  forceps  and  sutured,  as  shown  in  Fig.  492.  A  chromic  catgut  suture  is 
passed  in  two  rounds.  In  some  instances  it  will  be  desirable  to  place  two 
such  sutures. 

Eeinforcing  silkworm-gut  sutures,  commonly  used  in  other  methods  of 
sphincter  repairs,  in  this  particular  operation  are  not  necessary. 

4.  Shortening  of  the  pelvic  sling.  After  the  sphincter  injury  has  been 
repaired,  the  levator  sling  is  shortened  in  the  usual  way  as  shown  in  Fig.  493. 


Fig.  493.  The  approximation  of  the  edges  of 
the  sling  is  accomplished  exactly  as  in  the  operation 
for  incomplete  laceration,  Fig.  482. 


Fig.  494.     The    wound    is    closed    by    means    of 
continuous   suture. 


The  more  superficial  tissues  are  then  sutured  and  the  wound  is  closed  (Fig. 
494). 

After-treatment  in  Repair  of  the  Pelvic  Floor.  The  details  of  the  care  of 
a  patient  after  repair  of  the  pelvic  floor  may  be  grouped  as  follows : 

a.  Knees  Together.  For  the  first  twenty-four  hours  after  operation  it  is 
Avell  to  have  the  patient's  knees  held  together  by  a  bandage  around  them, 
a  thick  pad  of  cotton  being  placed  between  the  knees  to  prevent  discomfort. 
After  the  first  day  or  tAvo,  the  knees  may  be  released,  unless  the  patient  is 
very  nervous  and  restless.  Ordinarily,  the  pain  on  separation  of  the  thighs  is 
decided  enough  to  prevent  injurious  separation. 

b.  Changestg  the  Dressing.  The  genitals  and  pubic  region  must  be  kept 
covered  with  a  large  sterile  dressing  of  absorbent  cotton  or  gauze.     When 


556  RELAXATION    AND   FISTULAE 

tlie  dressing  has  to  be  removed  for  any  cause,  for  example,  to  allow  the  pa- 
tient to  urinate,  the  nurse  should  proceed  as  follows : 

Remove  the  dressing,  slip  the  bed-pan  under  the  patient  and  allow  her  to 
urinate.  Cleanse  the  genitals  by  pouring  a  1-5000  bichloride  solution  over 
them  from  a  sterile  pitcher  (pitcher  douche).  Remove  the  bed-pan,  apply  a 
fresh  sterile  dressing  and  reapply  the  T-bandage.  If  the  patient  complains 
of  persistent  smarting  from  the  bichloride  solution,  a  weak  carbolic  solution 
or  lysol  solution  may  be  used  instead  of  the  bichloride. 

c.  Relief  of  Pain.  After  a  thorough  repair  of  the  pelvic  floor  there  is,  as 
a  rule,  considerable  pain  for  the  first  few  days.  This  consists  of  superficial 
smarting  and  deep  aching  and  occasional  sharp  pains  due  to  muscular  ac- 
tion. All  these  are  relieved  considerably  by  hot  moist  packs  applied  to  the 
perineum.  Disinfect  the  hands  and  then  take  a  large  thick  piece  of  absorb- 
ent cotton,  as  large  as  the  two  hands,  soak  in  hot  carbolic  solution  (%%), 
squeeze  it  suificiently  to  prevent  dripping  and  then  apply  it  while  steaming 
to  the  perineum.  Put  a  large  piece  of  oiled  silk  over  the  cotton,  to  keep  in 
the  moisture,  and  then  reapply  the  T-bandage.  Outside  this  it  is  well  to 
place  a  hot-water  bag,  to  maintain  the  heat.  This  hot  application,  changed 
as  often  as  it  becomes  cool,  usually  gives  considerable  relief  and  may  be  used 
frequently,  or  if  necessary  almost  continuously,  for  the  first  few  days. 

If  the  smarting  is  very  troublesome,  carbolic  or  lysol  solution  may  be 
used  for  cleansing  the  parts.  If  the  aching  and  pain  is  still  sufficiently 
troublesome  to  prevent  rest,  give  sodium  bromide  as  necessary  to  allay  nerv- 
ousness and  secure  sleep,  particularly  at  night.  If  the  shooting  pains  through 
the  perineum  are  persistent,  it  may  be  necessary  to  give  codeine  phosphate 
hypodermatically  or  by  the  mouth,  in  half-grain  doses,  repeated  as  often  as 
necessary  to  give  rest. 

The  pains  and  soreness  gradually  disappear  and  after  the  first  few  days, 
as  a  rule,  no  sedatives  are  required. 

d.  Diet.  The  day  after  operation  liquid  diet  is  given,  and  after  that  ordi- 
nary light  diet,  until  the  bowels  have  moved  freely,  when  regular  diet  is 
gradually  resumed. 

When  the  laceration  has  extended  through  the  sphincter  ani,  the  patient 
should  be  kept  on  liquid  diet  exclusively  until  after  the  first  bowel  move- 
ment. In  such  a  case  there  should  be  no  bowel  movement  for  four  full  days, 
and  if  necessary  some  mixture  such  as  bismuth  and  opium  is  given  to  hold  the 
bowels  in  check  that  long. 

e.  Care  of  Bladder.  If  the  patient  can  pass  the  urine  herself,  the  author 
prefers  to  have  her  do  so.  The  catheter  should  be  used  only  if  necessary. 
Aside  from  the  ever-present  danger  of  cystitis,  the  use  of  the  catheter  is  a  dis- 
advantage in  that  manipulations  necessary  to  catheterization  disturb  the 
parts  and  do  more  harm  than  the  contact  of  healthy  urine,  especially  as  the 
urine  is  at  once  removed  by  the  cleansing  solution. 

In  many  cases,  however,  particularly  with  deep  lacerations,  the  patient 


AFTER-TREATMEXT  557 

can  not  urinate  at  first  and  must  be  catheterized  for  one  or  more  daj's.  The 
frequency  of  catheterization  depends  somcAvhat  on  the  quantity  of  urine  se- 
creted. Ordinarily  it  is  required  about  every  eight  hours.  For  the  details 
of  catheterization  see  Chapter  xvi. 

f.  Vaginal  Douches.  Ordinarily,  it  is  preferable  not  to  disturb  the  interior 
of  the  vagina  with  douches  for  the  first  three  days.  After  that  it  is  well  to 
give  a  bichloride  douche  (1-5000)  or  lysol  douche  once  daily.  In  introduc- 
ing the  douche  nozzle,  the  nurse  should  be  careful  to  carry  the  point  along 
the  anterior  vaginal  wall  so  that  there  may  be  no  chance  of  its  going  into  the 
wound  in  the  posterior  wall. 

g'.  Care  of  the  Bowels.  After  repair  of  the  ordinary  laceration,  the 
bowels  should  be  moved  in  two  days  by  a  purgative.  Several  hours  after 
the  purgative  is  taken,  when  the  patient  has  a  desire  for  bowel  movement, 
an  enema  of  two  ounces  of  olive  oil  in  a  pint  of  water  may  be  given.  This 
softens  the  fecal  masses,  lubricates  the  rectum  and  does  not  cause  the  smart- 
ing that  is  often  so  troublesome  after  the  ordinary  soap-water  enema.  After 
that,  laxatives  should  be  given  as  necessary  to  secure  one  or  two  bowel  move- 
ments daily. 

In  those  cases  where  it  has  been  necessary  to  repair  the  sphincter  ani 
muscle  and  rectal  wall,  there  should  be  no  bowel  movement  for  four  full  days. 
If  necessary,  some  preparation  should  be  given  to  keep  the  bowels  quiet  and 
prevent  movement.  When  it  is  time  for  the  bowels  to  move,  a  purgative  is 
given  and  when  the  desire  for  defecation  comes  on,  two  to  four  ounces  of 
olive  oil  should  be  injected  high  into  the  rectum  and  allowed  to  remain  for 
some  time.  The  oil  softens  the  fecal  masses  and  at  the  same  time  lubricates 
all  the  surfaces,  so  there  is  much  less  danger  of  the  rectal  wound  being  torn 
open.  AYlien  there  has  been  repair  of  the  rectal  wall,  usually  avoidable  by 
the  Ristine-"Watkins  operation,  the  small  oil  enema  is  better  than  the  large 
water  enema,  as  the  large  quantity  of  water,  if  injected  into  the  rectum  only, 
may  stretch  the  wall  and  open  the  wound.  Great  care  is  necessary  in  giving 
the  first  enema  after  repair  of  a  laceration  extending  into  the  rectum,  and 
unless  the  nurse  has  had  experience  in  such  eases  the  physician  had  better 
give  it  himself.  If  the  point  of  the  syringe  is  directed  too  far  forward  it  is 
apt  to  break  open  the  rectal  wound.  On  that  account  it  is  well  not  to  in- 
troduce the  hard  rubber  syringe  point  into  the  rectum  but  to  introduce  a  soft 
rubber  catheter  and  give  the  injection  of  oil  through  that.  The  patient 
should  be  cautioned  to  avoid  all  straining  efforts  in  defecation.  If  the  bowels 
do  not  move  easily  and  without  straining,  she  should  wait  for  a  repetition  of 
the  needed  enema  or  purgative. 

h.  Eemovixg  the  Sutures.  If  silkworm-gut  sutures  have  been  used,  they 
are  removed  in  eight  to  twelve  days.  By  that  time  they  have  usually  be- 
gun to  cut  into  the  tissues  and  no  longer  give  support.  If  some  suture  causes 
irritation  it  may  be  removed  any  time  after  the  fifth  day,  but  unless  there  is 
marked  irritation   all  the   sutures  should  be  left  until  they   are   absorbed. 


558  RELAXATION   AND   FISTULAE 

The  inside  sutures  in  the  vagina  and  in  the  rectum  take  care  of  themselves, 
i.  Getting  Up.  The  patient  should  be  kept  in  bed  three  full  weeks.  She 
may  then  be  allowed  out  of  bed  gradually,  each  day  more  and  more,  so  that 
by  the  end  of  the  fourth  week  she  is  ready  to  leave  the  hospital.  If  the  pa- 
tient is  allowed  up  too  soon,  there  may  be  stretching  of  the  newly-healed  tis- 
sues and  recurrence  of  the  old  trouble.  It  may  seem  strange  that  the  patient 
is  kept  in  bed  longer  than  for  an  abdominal  section,  but  there  is  good  reason 
for  it.  So  much  strain  comes  on  the  pelvic  sling  as  soon  as  the  patient  as- 
sumes the  upright  posture,  that  stretching  of  the  repaired  sling  is  very  likely 
to  take  place  unless  the  scar-tissue  has  had  time  to  become  firm. 

j.  General  after-care.  It  is  a  good  plan  to  take  advantage  of  the  patient's 
confinement  to  bed  to  improve  her  general  health.  Many  of  these  patients 
are  weak,  anemic,  nervous  and  generally  ''run  down,"  as  a  result  of  the  long 
continued  pelvic  distress.  In  such  a  case,  after  the  first  three  or  four  days, 
put  the  patient  on  a  good  tonic,  containing  iron  and  such  additional  drugs  as 
may  be  indicated  in  the  particular  case.  The  patient  may  be  given  large  quan- 
tities of  milk  in  addition  to  the  other  food,  both  at  regular  meal  times  and 
between  meals  and  at  night,  the  amount  of  nourishment  taken  each  tewnty- 
four  hours  being  gradually  increased  as  the  patient  can  bear  it.  In  many  cases 
it  is  of  much  benefit  to  employ  massage,  passive  movements,  salt-rubs  and  the 
various  other  measures  used  in  the  "rest  cure"  for  neurasthenia. 

The  tonics  should  in  most  cases  be,  continued  two  or  three  months  after 
the  patient  leaves  the  bed.  The  bowels  must  be  regulated  by  laxatives  so 
there  will  be  no  straining.  Heavy  lifting  must  be  avoided.  Sexual  inter- 
course should  be  postponed  for  at  least  one  month  after  the  patient  is  up  and 
about. 

COLPOCELE,  RECTOCELE,  CYSTOCELE 

In  many  cases  of  laceration  of  the  pelvic  floor,  there  is  considerable  pro- 
trusion of  the  vaginal  walls,  constituting  colpocele.  It  may  be  the  posterior 
vaginal  wall  (posterior  colpocele— Fig.  222)  or  it  may  be  the  anterior  vag- 
inal (anterior  colpocele). 

If  the  rectal  wall  follows  the  prolapsing  posterior  vaginal  wall,  the  con- 
dition is  called  rectocele  (Figs.  223,  224,  227,  228,  229,  230).  Rectocele,  is,  of 
course  corrected  by  the  regular  repair  of  the  pelvic  floor. 

If  the  bladder  follows  the  prolapsing  anterior  vaginal  wall,  the  condition 
is  called  cystocele  (Figs.  223,  224,  225,  226).  Cystocele,  when  present,  re- 
quires a  special  operative  measure  for  its  cure,  hence  it  is  necessary  to  give 
it  some  particular  consideration. 

Rectocele 

A  moderate  rectocele  is  taken  care  of  by  the  regular  repair  of  the  pelvic 
floor.    A  marked  rectocele  requires  special  suturing.    The  vaginal  flap  is  sepa- 


CYSTOCELE 


559 


rated  very  high — in  some  cases  two-thirds  of  the  distance  to  the  cervix  uteri. 
Then,  before  the  deep  muscular  sutures  are  passed,  the  anterior  rectal  wall  is 
folded  in  by  two  or  three  rows  of  buried  sutures.  After  that  the  pelvic  sling  is 
shortened  by  the  usual  subvaginal  approximation. 

Cystocele 

Cystocele  of  the  most  severe  type  occurs  in  conjunction  with  prolapse 
of  the  uterus,  and  its  correction  constitutes  one  of  the  important  features  in 
operation  for  prolapse.  In  fact,  in  many  of  the  severe  cases  the  most  impor- 
tant problem  is  the  permanent  correction  of  the  cystocele,  the  correction  of 
the  uterine  prolapse  being  only  incidental.     This  is  evident  from  a  study  of 


Fig.   495.     Median    incision    for    cystocele    operation. 


Fig.  496.  The  vaginal  flap  on  either  side  is 
pushed  off  from  the  underlying  tissues  by  means 
of  the   finger  covered   with   gauze. 


the  various  effective  operations  for  severe  prolapse.  The  treatment  for  severe 
cystocele,  therefore,  will  be  found  in  Chapter  vii. 

Cystocele  of  moderate  degree,  not  complicated  by  uterine  prolapse  or 
retrodisplacement,  may  be  corrected  by  simple  repair  of  the  utero-pubic  fas- 
cia followed  by  repair  of  the  pelvic  floor.  This  work  through  the  anterior 
vaginal  wall  is  often  referred  to  as  anterior  ' '  colporrhaphy, "  but  it  should 
go  much  deeper  than  suture  of  the  vaginal  wall.  It  should  bring  together  the 
deep  fascial  structures,  as  shown  in  Figs.  495  and  496.  The  steps  in  the  work 
are  as  follows: 

1.  Incision  through  the  anterior  vaginal  ivall.  This  extends  from  the 
vaginal  entrance  baekAvard  to  the  cervix  uteri  (Fig.  495).  To  make  the  wall 
tense,  to  facilitate  incision,  it  is  caught  at  the  anterior  and  i^osterior  ends  of 


560  RELAXATIOX    AND    FISTULAE 

the  intended  incision,  with  tenaculnm  forceps.  The  posterior  tenaculum  for- 
ceps is  placed  just  in  front  of  the  cervix,  which  it  pushes  backward  and 
downward  in  the  pelvis,  in  order  to  make  tense  the  anterior  vaginal  wall. 

It  is  important  in  these  cases  to  avoid  the  common  practice  of  drawing 
the  cervix  outside  the  vagina.  There  is  no  marked  uterine  prolapse  or  retro- 
displacement  in  the  cases  under  consideration;  and  if,  to  correct  the  moder- 
ate eystocele  the  cervix  is  drawn  outside  the  vaginal  entrance,  the  utero-sa- 
cral  ligament  and  broad  ligaments  are  overstretched  and  the  patient  is  in 
worse  condition  at  the  close  of  the  operation  than  she  was  at  its  beginning. 
The  overstretched  uterine  supports  will  probably,  sooner  or  later,  permit  re- 
trodisplacement  and  prolapse.  Of  course,  where  there  is  already  marked 
prolapse,  no  harm  results  from  dra^^dng  the  cervix  outside  the  vagina  for 
work  on  the  utero-pubic  fascia;  for  the  ligaments  are  already  relaxed  and 
the  relaxation  is  taken  care  of  in  the  subsequent  steps  of  the  prolapse  oper- 
ation. It  is  quite  different,  however,  in  the  eases  under  consideration,  in 
which  no  prolapse  is  present.  Here,  the  posterior  supporting  ligaments  of 
the  cervix  uteri  are  intact,  and  it  is  important  to  preserve  them  intact  even 
though  such  preservation  makes  the  work  decidedly  more  inconvenient. 

This  same  error  (drawing  the  cervix  too  far  forward)  is  frequently 
made  in  doing  a  simple  curettage — the  overstretching  of  the  utero-sacral  and 
broad  ligaments  leading  to  subsecjuent  retrodisplacement  as  explained  in  Chap- 
ter VI. 

2.  Separation  of  the  vaginul  wall  from  the  underlying  tissues.  The  margin 
of  the  tlap  is  freed  by  scissors  or  knife.  It  is  then  grasped  with  a  forceps 
and  the  underlying  tissues  rolled  off  with  the  gauze-covered  finger  (Fig.  496). 
When  both  flaps  have  been  well  separated,  the  excess  of  vaginal  wall  is 
trimmed  away  (Fig.  480),  leaving  just  enough  to  meet  in  the  median  line 
over  the  repaired  fascia.  If  preferred,  the  trimming  of  the  vaginal  flaps  may 
be  delayed  until  after  the  fascial  repair. 

3.  Shortening  of  the  utero-puhic  fascial  plane  transversely.  This  is  accom- 
plished by  two  or  three  rows  of  buried  sutures  as  indicated  in  Figs.  497  and 
498.  The  greater  the  relaxation,  the  more  rows  of  sutures  required.  Suf- 
ficient sutures  should  be  passed  to  take  up  the  slack  and  form  a  firm  side-to- 
side  supporting  sling  beneath  the  bladder. 

The  tissues  of  the  utero-pubic  fascial  plane  are  rolled  off  the  vaginal 
flap  with  the  bladder.  They  remain  attached  to  the  bladder  wall,  and  the 
plication  of  the  plane,  as  here  carried  out,  consists  in  turning  in  and  sutur- 
ing this  apparently  thickened  bladder  wall — that  is,  the  fascial  plane  and  the 
bladder  wall  are  manipulated  together.  On  the  other  hand,  in  those  very  severe 
cases  associated  yn\\i  uterine  prolapse,  where  it  is  necessary  to  separate  the 
bladder  entirely  from  the  uterus,  there  is  more  or  less  separation  of  the  blad- 
der from  the  utero-pubic  plane,  particularly  in  its  posterior  half. 

4.  Closure  of  the  vaginal  u-ound.    This  is  accomplished  by  a  running  suture. 


RECTO-VAGINAL   FISTULA 


561 


as  indicated  in  Fig.  498.  The  suture  is  of  chromic  catgut  and  should  be  se- 
curely locked  at  intervals.  If  preferred,  the  suture  may  be  half-locked  all  the 
Avay.  The  half-locked  suture  is  an  excellent  one  where  there  is  bleeding  from 
the  edges. 

It  is  usually  more  convenient  to  begin  the  closing  suture  at  the  posterior 
end  of  the  wound,  and  finish  at  the  anterior  end,  as  shown  in  the  illustration. 


Fig.  497.  The  first  row  of  buried  sutures,  ap- 
proximating the  deep  tissues  (utero-pubic  fascial 
plane)   is  finished,  and  second  row  is  started. 


Fig.  498.  After  finishing  the  second  row,  the 
excess  of  vaginal  wall  is  trimmed  away  and  the 
wound  closed. 


RECTO-VAGINAL  FISTULA 

Prom  injuries  in  labor  or  from  destructive  ulceration  or  from  other 
causes,  fistulous  openings  may  form,  extending  in  various  directions.  The 
different  varieties  of  genital  fistulae,  with  the  name  given  to  each,  are  shown 
in  Fig.  499. 

A  Recto-vaginal  Fistula  is  an  opening  from  the  rectum  into  the  vagina. 
The  size  of  the  fistula  may  vary  from  a  small  tortuous  tract,  admitting  only 
a  small  probe  and  permitting  only  gas  or  fluid  to  escape,  to  a  large  opening, 
involving  a  large  part  of  the  recto-vaginal  septum,  and  through  which  pass 
practically  all  the  rectal  contents. 


Etiology  and  Pathology 

The  following  are  the  causes  of  recto-vaginal  fistulae : 
1.  Injuries  in  Labor.    In  rare  cases  a  hole  may  be  torn  through  the  recto- 
vaginal septum,  resulting  directly  in  a  fistula.    Usually,  however,  a  fistula  re- 
sulting from  labor,  is  due  to  a  complete  laceration  of  the  perineum,  which  is 


562 


RELAXATION    AND   FISTULAE 


repaired  at  once  or  later,  but  fails  to  heal  entirely.  The  lower  part  of  the 
approximated  surfaces  unites  but  a  small  part  of  the  upper  angle  fails  to  heal, 
and  the  result  is  a  fistula  extending  from  the  rectum  into  the  vagina. 

2.  Chronic  Ulceration  of  the  posterior  vaginal  wall,  which  may  be  chan- 
croidal or  syphilitic  or  tubercular.  It  usually  affects  the  lower  part  of  the  va- 
gina. 

3.  Stricture  of  the  Rectum,  with  dilatation  and  ulceration  of  the  rectal 
wall  above  it. 


Fig.  499.  Fistulae  of  the  Genital  Tract. 
Recto-vaginal  fistula.  4.  Vesico-uterine  fistula. 
(Gilliam — Practical   Gynecology.) 


I.    Urethro-vaginal    fistula. 
5.     Uretero-vaginal     fistula. 


?.    Vesico-vaginal    fistula.      3. 
6.    Intestine-vaginal    fistula. 


4.  Malignant  Disease  of  the  recto-vaginal  septum.  This  is  usually  second- 
ary to  cancer  of  the  cervix  uteri  or  cancer  of  the  rectum. 

5.  Operation.  A  pelvic  abscess  which  has  ruptured  into  the  rectum,  will, 
if  opened  into  from  the  vagina,  give  a  recto-vaginal  fistula.  Again,  in  stric- 
ture of  the  rectum,  there  may  be  dilatation  and  ulceration  of  the  rectal  wall 
above  the  stricture  with  perirectal  inflammation  and  an  abscess.  Such  an  ab- 
scess, if  opened  into  from  the  vagina,  will  give  a  recto-vaginal  fistula.  Again, 
the  rectal  wall  may  be  injured  directly  in  various  operations. 


EECTO-VAGINAL   FISTULA  563 

Diagnosis 

The  diagnostic  symptoms  of  recto-vaginal  fistula,  are  the  escape  of  some 
of  the  rectal  contents  into  the  vagina  and  the  vaginal  irritation  caused  by 
the  same.  The  amount  and  character  of  the  leakage  from  the  rectum  varies 
much  in  different  cases.  In  the  smallest  fistulae,  only  gas  Avith  occasionally 
some  liquid,  passes.  With  the  opening  a  little  larger,  there  may  be  free  leak- 
age only  when  the  boAvels  are  loose  and  the  contents  fluid.  In  still  other 
eases,  nearly  all  the  rectal  contents,  whether  fluid  or  solid,  pass  through  the 
fistulous  opening. 

Digital  examination  reveals  a  rough  place  in  the  posterior  vaginal  wall.  If 
the  opening  is  small,  only  a  small  elevation  or  depression  or  a  rough  place,  is 
felt.  On  inspection,  if  the  opening  is  large  it  may  be  seen;  but  if  small,  only 
a  rough  place  with  a  small  slit  is  visible.  Very  often  a  red  papule  marks  the 
vaginal  opening  of  the  fistula.  Exploration  of  the  opening  with  a  probe,  vnth 
a  finger  of  the  other  hand  in  the  rectum,  shows  that  the  sinus  communicates 
with  the  rectum.  In  a  doubtful  case  in  Avhich  the  opening  can  not  be  found 
or  in  which  a  probe  can  not  be  introduced,  the  fact  that  there  is  a  recto-vag- 
inal fistula  may  be  established  and  its  location  determined  by  injecting  col- 
ored water  (methylene  blue,  %%  solution)  into  the  rectum  and  watching 
for  its  appearance  on  the  posterior  vaginal  wall.  If  there  is  syphilitic  or 
chancroidal  or  tubercular  ulceration,  or  if  there  is  a  stricture  of  the  rectum 
or  malignant  disease,  the  evidences  of  the  complicating  disease  Avill  be  pres- 
ent, in  addition  to  the  evidences  of  fistula. 

Treatment 

In  the  recto-vaginal  fistula  following  labor,  that  is,  where  part  of  the 
repaired  recto-vaginal  septum  failed  to  heal,  no  secondary  operation  should 
be  undertaken  for  the  closure  of  the  fistula  for  six  or  eight  weeks  after  la- 
bor. The  fistula  may  close  spontaneously  within  a  few  weeks.  Again,  an 
operation  in  the  genital  tract  in  the  puerperium  increases  the  chances  of  puer- 
peral sepsis.  Also,  the  patient  is  later  in  much  better  condition  generally  for 
the  operation,  as  she  has  recovered  from  the  debilitating  effects  of  parturition. 
Locally,  also,  the  tissues  have  returned  to  their  normal  condition,  and  com- 
plete primary  union  is  much  more  certain  to  follow  the  operation.  For  some 
time  follo^wing  labor  the  uterine  discharge  would  tend  to  interfere  with  heal- 
ing and  the  tissues  are  so  friable  that  the  sutures  are  much  more  liable  to 
cut  through. 

Palliative  Treatment.  In  the  meantime,  the  vagina  must  be  kept  clean 
by  antiseptic  vaginal  douches,  once,  twice  or  three  times  daily,  as  indi- 
cated by  the  amount  of  leakage  through  the  opening.  If  the  opening  is  very 
small,  stimulation  by  touching  it  occasionally  with  silver  nitrate  stick  or  with 
carbolic  acid,  will  sometimes  cause  the  fistula  to  close.    If  the  fistula  persists 


564  RELAXATION   AND   FISTULAE 

after  thorough  recovery  from  the  parturition,  it  may  be  closed  by  operation. 

Operation. — In  the  simple  form  of  fistula,  without  complicating  ulceration 
or  infiltration,  the  operation  for  closure  may  be  undertaken  without  special 
local  preparatory  treatment. 

The  preparation  of  the  patient,  operator,  instruments  and  dressings  are 
the  same  as  for  repair  of  complete  laceration  of  the  pelvic  floor. 

Steps.  The  patient  is  placed  in  the  dorsal  posture  and  the  fistula  exposed 
by  retractors  or  by  the  fingers  of  an  assistant  as  is  found  most  convenient. 
The  sphincter  ani  muscle  should  be  temporarily  paralyzed  by  stretching  be- 
fore beginning  the  operation  proper. 

The  vicinity  of  the  fistula  is  then  denuded  as  shown  in  Fig.  500.  The 
denudation  may  be  made  with  scissors  or  knife,  as  found  most  convenient. 
This  removes  all  scar-tissue  along  the  fistulous  tract  and  gives  healthy  de- 
nuded tissue  for  approximation.  A  large  area  should  be  denuded  on  the  vag- 
inal surface,  and  this  as  it  goes  deeper  should  slant  gradually  toward  the 
point  at  which  the  fistula  enters  the  rectum. 

The  opening  in  the  rectum  should  not  be  made  larger  than  is  absolutely 
necessary  to  remove  the  hard  scar-tissue  from  the  opening  and  to  denude 
the  edges  of  the  rectal  mucosa,  so  that  when  these  edges  are  brought  to- 
gether union  mil  take  place. 

The  sutures  are  passed  as  follows:  The  needle  enters  the  vaginal  mu- 
cosa a  short  distance  outside  the  area  of  denudation,  passes  to  the  bottom  of 
the  wound,  is  brought  out  in  the  denuded  edge  of  the  rectal  mucous  mem- 
brane, enters  at  a  corresponding  point  on  the  opposite  side  and  emerges  from 
the  vaginal  mucosa.  When  this  suture  is  tied  it  approximates  the  denuded 
area  in  the  entire  thickness  of  the  vaginal  wall  and  also  the  denuded  edge 
of  the  rectal  mucosa,  but  the  suture  does  not  touch  the  free  surface  of  the 
rectal  mucosa.  It  is  important  that  the  suture  should  not  penetrate  to  the 
interior  of  the  rectum  as  the  rectal  contents  might  cause  inflammation  along 
its  tract.  The  sutures  are  placed  about  one-fourth  of  an  inch  apart,  and  in 
such  a  way  that  when  tied,  the  line  of  approximation  lies  in  the  long  axis  of 
the  vagina.  If  desired,  the  deeper  portions  of  the  wound  may  be  closed  with 
buried  catgut  sutures,  as  explained  under  Vesico-Vaginal  Fistula  (Fig.  500). 
A  wider  surface  for  approximation  may  be  secured,  without  loss  of  tissue, 
by  splitting"  the  edges  of  the  opening  and  approximating  the  raw  surface 
of  the  rectal  flaps  by  buried  catgut,  and  approximating  the  raw  surface  of 
the  vaginal  flaps  by  catgut  or  silkworm-gut.  In  the  flstula  with  a  small  rec- 
tal opening  the  above  is  the  method  of  suturing  to  be  employed. 

When  there  is  a  large  opening  into  the  rectum,  it  may  be  necessary  to 
close  the  opening  in  the  rectal  mucosa  with  a  separate  row  of  sutures  passed 
from  the  rectal  surface  and  tied  in  the  rectum.  In  order  to  do  this,  it  is 
necessary  to  dilate  the  sphincter  ani  widely  so  that  the  rectal  end  of  the  fis- 
tula may  be  reached  for  suturing.  The  denudation  is  made  the  same  as  pre- 
viously described.     The  rectal  sutures  include  only  the  rectal  mucosa  and  a 


recto-vaginaij  fistui^a  565 

small  amount  of  submucous  tissue.  After  the  opening  in  the  rectal  mucosa 
has  been  closed  the  remainder  of  the  wound  is  closed  by  sutures  from  the 
vaginal  surface  as  already  described. 

In  a  case  of  large  fistulous  opening  near  the  anus,  better  approximation 
can  be  secured  by  dividing  the  tissues  between  the  fistula  and  the  anus,  thus 
converting  the  fistula  into  a  complete  laceration  of  the  perineum,  which  is 
then  repaired  in  the  ordinary  way. 

The  after-treatment.  The  after-treatment  of  a  case  of  recto-vaginal  fis- 
tula is  the  same  as  after  repair  of  complete  laceration  of  the  pelvic  floor. 

Special  Measures.  In  some  cases  there  has  been  so  much  loss  of  tissue 
that  the  sides  of  the  opening  can  not  be  satisfactorily  approximated.  This 
marked  loss  of  tissue  may  be  due  to  extensive  ulceration  at  the  time  the  fis- 
tula was  formed,  or  to  repeated  attempts  at  repair.  In  either  case  the  vicinity 
of  the  opening  is  occupied  by  scar-tissue,  extending  in  various  directions  and 
making  the  parts  so  rigid  that  the  opening  can  not  be  satisfactorily  closed  ex- 
cept by  the  employment  of  one  of  the  following  special  measures : 

1.  Incisions  of  the  vaginal  mucous  membrane  some  distance  from  the 
opening,  to  permit  the  mucosa  being  drawn  over  the  opening  without  inju- 
rious tension.  Each  of  these  incisions,  if  made  short,  may  be  closed  immedi- 
ately by  passing  a  suture  in  the  long  axis  of  the  incision. 

2.  Transplantation  of  a  flap  of  vaginal  mucous  membrane,  the  flap  to 
receive  its  nourishment  through  an  unsevered  portion  at  one  or  both  ends. 

3.  Detachment  of  the  rectum  from  the  fixed  vagina,  by  incision  in  the 
perineum,  and  closure  of  the  rectal  wall  independently  of  the  vaginal  wall. 
In  certain  cases  of  large  recto-vaginal  opening,  the  vaginal  wall  is  bound  im- 
movably by  scar-tissue  and  the  sides  of  the  rectal  opening  are  likewise  held 
apart  by  their  attachment  to  the  vaginal  wall.  If  a  transverse  incision  be 
made  in  the  perineum  and  the  rectal  wall  dissected  from  the  vaginal  to  a 
considerable  distance  above  the  fistula,  it  then  becomes  freely  movable  and  the 
sides  of  the  opening  may  be  approximated.  They^  should  be  united  by  one 
or  two,  rows  of  sutures.  The  sutures  may  be  passed  from  the  opening  in  the 
vaginal  wall  from  the  perineal  wound,  as  found  most  convenient. 

If  the  fistula  is  complicated  by  ulceration,  the  ulceration,  of  whatever 
character,  should  be  healed  as  far  as  possible  before  the  attempt  is  made  to 
close  the  fistula.  In  some  of  these  cases,  the  patient  has  tertiary  syphilis  and 
needs  a  prolonged  course  of  treatment  for  the  ulceration  and  for  the  syphilitic 
deposit,  and  also  for  the  marked  anemia  and  generally  lowered  vitality  that 
accompanies  that  disease. 

In  the  syphilitic  cases,  if  closure  is  attempted  while  the  ulceration  is  still 
present  or  while  the  patient  is  anemic  and  weak  from  ulceration  elsewhere, 
the  operation  is  very  liable  to  result  in  failure  and  the  last  opening  may  be 
larger  than  the  first. 

In  a  tubercular  fistula  and  in  a  malignant  fistula,  it  is  useless  to  attempt 


566  RELAXATION   AND   FISTULAE 

closure  of  the  fistula  unless  the  infiltrated  area  can  be  excised  and  healthy 
tissue  approximated  by  the  sutures. 

Other  Fecal  Fistulae 

Occasionally  there  occur  other  varieties  of  fecal  fistula,  opening  into  the 
genital  tract.  There  may  be  an  opening  into  the  vagina  from  the  sigmoid 
flexure  or  from  the  colon  or  from  the  small  intestine.  There  may  be  an  open- 
ing into  the  uterus  from  the  sigmoid  or  from  the  colon  or  from  the  small 
intestine. 

The  most  common  form  is  that  following  some  operation  at  the  vaginal 
vault,  particularly  vaginal  hysterectomy.  It  appears  in  the  form  of  a  small 
opening  in  the  scar  at  the  vaginal  vault,  from  which  intestinal  gas  or  fluid 
escapes.  It  is  caused  by  injury  of  the  intestine  during  operation  or  by  ulcer- 
ation of  the  intestinal  wall  before  or  after  operation.  The  injury  may  be 
caused  by  a  bite  of  the  bowel  by  the  tip  of  the  pressure  forceps,  by  a  punc- 
ture of  the  bowel  by  a  needle  or  ligature  carrier,  by  inclusion  of  a  small  por- 
tion of  the  bowel  in  a  ligature  as  it  is  being  tied  or  by  partial  or  complete 
rupture  of  the  bowel  in  breaking  up  adhesions.  Sometimes  a  tubal  abscess 
is  discharging  into  the  large  or  small  intestine  and,  when  such  an  abscess 
cavity  is  opened  by  vaginal  incision,  a  fecal  fistula  results. 

Fecal  fistulae  involving  the  vault  of  the  vagina  often  close  spontaneously 
after  a  few  weeks,  the  vagina  in  the  meantime  being  kept  clean  by  antiseptic 
douches. 

If  the  fistula  persists  after  several  weeks  with  no  apparent  prospect  of 
closing  it  will  be  necessary  to  close  it  by  an  operation  involving  abdominal 
section  or  vaginal  section.  The  character  of  the  operation  required  will  de- 
pend on  the  character  of  the  fistula.  It  should  be  undertaken  only  by  one 
skilled  in  pelvic  surgery  for  conditions  very  difficult  to  handle  may  be  en- 
countered. 

The  other  forms  of  genito-intestinal  fistula  are  rare,  so  rare  that  iliej 
are  curiosities.  They  are  due  to  special  causes  and  require  special  treatment, 
usually  involving  abdominal  section. 

VESICO-VAGINAL  FISTULA 

There  may  be  an  opening  between  the  genital  tract  and  the  urinary  tract 
at  one  of  several  situations  (Fig.  499).  The  location  is  indicated  by  the 
name  as  follows : 

Urethro-vaginal  Fistula — Between  Urethra  and  Vagina. 
Vesico-vaginal  Fistula — Between  Bladder  and  Vagina. 
Uretero-vaginal  Fistula — Between  Ureter  and  Vagina. 
Vesico-uterine  Fistula — Between  Bladder  and  Uterus. 
Uretero-uterine   Fistula — Between   Ureter   and   Uterus. 

All  of  these  fistulae  are  rare,  the  most  common  being  the  vesico-vaginal. 


VESICO-VAGINAL   FISTULA  567 

A  vesico-vaginal  fistula  is  an  opening  from  the  bladder  into  the  vagina.  The 
size  of  the  fistula  may  vary  from  a  small  opening,  permitting  only  slight 
leakage,  to  a  large  opening  through  which  all  the  urine  passes. 

Etiology 

The  following  are  the  causes  of  the  vesico-vaginal  fistula : 

1.  Injuries  in  Labor.  In  prolonged  labor  where  the  lower  portion  of  the 
bladder  is  caught  and  held  for  several  hours  between  the  head  and  the  pubic 
bone,  sloughing  may  follow.  Part  of  the  base  of  the  bladder  and  the  an- 
terior vaginal  wall  are  bruised,  the  circulation  is  more  or  less  cut  off,  the 
parts  become  gangrenous  and  after  a  few  days  the  slough  separates,  leaving 
a  vesico-vaginal  opening  through  which  the  urine  passes.  Such  injuries  are 
rare  in  recent  years  on  account  of  the  great  improvement  in  obstetric  teach- 
ing and  practice.  Now,  the  head  is  not  permitted  to  remain  for  several  hours 
in  such  a  position  that  it  makes  serious  pressure  on  the  bladder.  If  the  head 
does  not  advance  satisfactorily  within  a  reasonable  time  after  the  rupture 
of  the  membranes,  the  child  is  delivered  by  forceps  or  otherwise. 

A  still  rarer  form  of  damage  to  the  bladder  in  labor  is  that  in  which  the 
bladder  is  torn  directly,  either  by  the  manipulations  incident  to  a  version 
or  by  the  forceps.  In  that  case  the  dribbling  of  urine  is  noticed  immediately, 
or  within  a  few  hours  after  labor,  whereas  if  the  fistula  is  due  to  sloughing, 
there  is  no  escape  of  urine  until  the  separation  of  the  slough,  which  requires 
several  days. 

2.  Chronic  Ulceration  of  the  anterior  vaginal  wall  or  the  base  of  the  blad- 
der.   The  ulceration  may  be  chancroidal,  syphilitic  or  tubercular. 

3.  Malignant  Disease  of  the  vesico-vaginal  septum.  This  is  usually  sec- 
ondary to  cancer  of  the  cervix  uteri. 

4.  Operations.  One  of  the  methods  of  treating  severe  chronic  cystitis 
is  to  make  an  opening  from  the  vagina  into  the  base  of  the  bladder,  so  as 
to  give  constant  drainage  of  the  latter.  Such  an  opening  usually  closes  spon- 
taneously a  short  time  after  the  drainage  tube  is  removed.  It  may,  hoAvever, 
fail  to  6lose  promptly  after  its  usefulness  is  ended,  and  in  that  case  becomes 
a  vesico-vaginal  fistula,  requiring  operation. 

Diagnosis 

The  patient  complains  of  urine  coming  from  the  vagina  and  of  much  A^ag- 
inal  irritation.  In  some  cases  the  patient  complains  simply  that  she  can  not 
control  the  urine. 

Digital  examination  reveals  a  rough  place  on  the  anterior  vaginal  wall. 
If  the  opening  is  large  it  may  be  distinctly  made  out  with  the  finger.  If  the 
opening  is  small,  only  a  slight  elevation  or  depression  or  rough  place  may  be 
felt.     Upon  inspection,  if  the  opening  is  large,  it  may  be  seen,  but  if  it  is 


568  RELAXATION"   AND   PISTULAE 

small,  only  a  rough  place  with  a  small  slit  is  visible.  Very  often  a  red  papule 
marks  the  vaginal  opening  of  the  fistula.  Exploration  of  the  opening  with  a 
probe,  with  a  sound  in  the  bladder,  shows  that  the  sinus  communicates  with 
the  bladder.  If  the  opening  be  watched  a  few  minutes,  urine  may  be  seen 
escaping  from  it.  If  the  diagnosis  is  doubtful,  sterile  methylene-blue  solution 
may  be  injected  into  the  bladder  and  its  appearance  watched  for  at  the  sup- 
posed vaginal  opening  of  the  fistula.  There  is  a  rare  condition  which  must 
be  carefully  differentiated  from  vesico-vaginal  fistula,  namely,  uretero-vag- 
inal  fistula. 

"When  the  vesico-vaginal  opening  is  large,  the  fact  that  it  communicates 
mth  the  bladder  is  apparent,  and  frequently  the  margins  of  the  opening  and 
the  adjacent  surfaces  of  the  vaginal  mucosa  and  vesical  mucosa  are  encrusted 
with  the  phosphates  from  the  decomposed  urine.  In  one  of  the  author's  eases 
there  was  a  large  phosphate  stone  nearly  filling  the  contracted  bladder  and 
projecting  through  the  large  vesico-vaginal  opening  into  the  vagina. 

The  irritation  caused  by  the  decomposition  of  urine  in  the  vagina  is  very 
great,  and  the  constant  odor  of  decomposing  urine  combined  with  the  constant 
leakage  of  fluid,  soaking  pads  and  clothing,  makes  the  patient's  very  existence 
a  burden  to  her. 

Treatment 

If  the  fistula  is  due  to  malignant  disease,  no  attempt  should  be  made  to 
close  it  unless  the  malignant  infiltration  is  so  situated  that  it  can  be  completely 
extirpated.  In  the  inoperable  cases,  local  cleanliness  and  local  sedatives  are 
indicated. 

If  the  fistula  has  resulted  from  sloughing  after  labor,  it  is  best  to  post- 
pone the  operation  for  repair  for  at  least  eight  weeks,  until  the  patient  has 
fully  recovered  from  parturition  and  the  tissues  have  become  strong  enough  to 
hold  the  sutures  well.  During  the  time  the  patient  is  waiting,  palliative  treat- 
ment will  be  necessary. 

Palliative  Treatment.  This  consists  in  keeping  the  parts  clean  and  in  re- 
ceiving and  disposing  of  the  urine,  so  that  it  does  not  come  in  contact  with 
the  clothing.  To  accomplish  the  first  object,  a  urinary  antiseptic  such,  as  uro- 
tropin  should  be  given  internally.  Also  a  vaginal  douche  of  borax  (a  table- 
spoonful  to  a  quart  of  water)  or  a  weak  carbolic  douche  {V2%)  should  be 
given  two  or  three  times  daily  and  the  external  genitals  should  be  washed 
frequently  with  a  carbolic  wash.  If  there  is  much  vulvar  irritation,  the  meas- 
ures mentioned  under  acute  vulvitis  may  be  employed.  For  catching  the 
urine  and  protecting  the  clothing,  one  of  the  urinals  found  in  the  instrument 
stores  may  be  used.  If  no  satisfactory  urinal  can  be  obtained,  an  absorbent 
cotton  pad  covered  with  a  large  piece  of  rubber-sheeting  may  be  used.  The 
piece  of  rubber-sheeting  is  held  in  place  by  a  suitable  bandage  and  the  pad  is 
changed  as  frequently  as  it  becomes  wet,  so  that  no  l^^kage  into  the  clothing 


OPERATION   FOR   VESICO-VAGINAL   FISTULA  569 

takes  place.    All  the  surfaces  with  which  the  "urine  comes  in  contact  may  be 
coated  twice  daily  with  benzoated  zinc-oxide  ointment. 

If  the  fistula  is  very  small,  cauterization  may  aid  spontaneous  closure. 
The  vaginal  portion  of  the  fistulous  tract  may  be  cocainized  and  then  touched 
with  carbolic  acid  or  nitric  acid.  An  occasional  stimulation  with  the  silver 
nitrate  stick  is  sometimes  useful.  If  after  the  patient  has  recovered  from 
parturition,  the  fistula  shows  no  evidence  of  early  closing,  an  operation  is 
indicated. 

Operation 

In  an  operative  case  of  vesico-vaginal  fistula  the  preparatory  measures 
are  important.  The  object  is  to  secure  a  healthy  condition  of  the  edges  of  the 
fistulous  opening.  These  edges  are  often  inflamed  and  covered  with  phos- 
phatic  deposits.  These  deposits  should  be  removed  with  cotton  and  the  raw 
surfaces  brushed  with  silver  nitrate  solution  (2%  to  4%)  or  some  of  the  other 
silver  preparations.  If  the  deposits  adhere  to  the  mucous  membrane  and  are 
difficult  to  remove,  they  may  be  dissolved  by  the  application  of  a  weak  nitric 
acid  solution  (one  or  two  drops  to  the  ounce).  Frequent  hot  vaginal  douches 
of  plain  water  or  borax  solution  or  weak  carbolic  solution,  are  beneficial,  as 
are  also  frequent  warm  sitz-baths.  After  the  douches  and  sitz-baths  the  pa- 
tient should  dry  the  parts  as  best  she  can  and  then  apply  the  zinc-oxide  oint- 
ment over  all  the  surfaces,  to  prevent  contact  with  the  urine. 

Every  second  or  third  day  the  physician  may  introduce  the  Sims  specu- 
?um,  cleanse  the  parts  thoroughly,  apply  the  silver  preparation  and  then  coat 
the  vaginal  walls  and  adjacent  surfaces  with  benzoated  zinc-oxide  ointment 
or  other  suitable  protective. 

The  urine  may  be  made  more  acid  and  the  tendency  to  phosphatic  de- 
posits thus  diminished,  by  giving  the  benzoic  acid  mixture  recommended  by 
Emmet.  After  a  few  days,  when  the  urine  is  strongly  acid  and  shows  but 
little  tendency  to  decomposition,  the  dose  of  the  benzoic  acid  mixture  may  be 
reduced  from  a  tablespoonful  to  a  teaspoonful,  as  the  larger  dose  may  pro- 
duce gastric  irritability.  This  urinary  antiseptic  or  some  similar  one  should 
be  continued  after  operation  to  prevent  phosphatic  deposit  about  the  bladder 
wound.  Also,  a  large  amount  of  pure  water  should  be  given  to  keep  the  urine 
well  diluted. 

The  same  general  preparation  of  the  patient  for  operation  should  be  car- 
ried out  as  for  repair  of  laceration  of  the  pelvic  floor.  Special  attention  must 
be  given  the  urine.  For  several  days  before  operation  the  patient  should  be 
given  some  urinary  antiseptic  every  six  or  eight  hours,  such  as  the  benzoic 
acid  mixture,  just  mentioned,  or  cystogen  or  urotropin  or  salol  and  boric  acid. 

A  specimen  of  urine  for  analysis  may  be  obtained  by  cleansing  the  vagina 
and  then  placing  a  bed-pan  under  the  patient  long  enough  to  collect  a  sufficient 
quantity. 

Before  operation  it  must  be  determined  that  the  urethra  is  not  closed  by 


570  RELAXATION   AND   FISTULAE 

shrinkage  from  non-use  and  inflammatory  adhesions.  In  some  cases  no  urine 
has  passed  through  the  urethra  for  months  or  years.  If  the  urethra  is  not  of 
proper  caliber  it  should  be  dilated  during  the  preparatory  treatment. 

The  technic  of  the  operation  for  vesico-vaginal  fistulae  is  indissolubly  con- 
nected with  the  name  of  J.  Marion  Sims.  The  rise  of  Sims  to  great  promi- 
nence was  due  largely  to  his  admirable  work  in  these  cases.  Up  to  his  time  the 
severer  grades  of  vesico-vaginal  fistula  were  considered  incurable,  and  every 
such  patient  was  consigned  to  lifelong  misery,  a  burden  to  herself  and  to  her 
associates.  Extensive  vesico-vaginal  fistula  following  labor  Avas  much  more 
common  then  than  it  is  now,  for  obstetric  teaching  had  not  then  advanced  to 
its  present  state.  Consequently  there  were  many  patients  in  the  various  coun- 
tries of  the  world  suffering  from  the  severer  forms  of  this  trouble,  and  all 
were  practically  without  hope  of  relief. 

Sims  took  hold  of  the  subject  and  perfected  the  means  for  exposing  the 
fistula — Sims'  speculum  and  Sims'  posture — and  also  the  instruments  and 
technic  for  suturing  with  silver  wire.  He  also  provided  for  constant  drainage 
of  the  bladder  during  healing,  by  the  use  of  a  retention  catheter. 

These  improvements  together  with  his  tactile  skill,  his  painstaking  care 
and  his  courageous  perseverance,  enabled  him  to  obtain  results  that  were  be- 
fore considered  impossible.  Apparently  hopeless  cases  were  made  well,  pa- 
tients were  restored  from  a  miserable  existence  to  a  happy  life  and  eventually 
the  fame  of  Sims  spread  everywhere  in  the  civilized  world — and  history  justly 
records  him  as  one  of  the  great  leaders  in  medical  progress  and  one  of  the 
great  benefactors  of  mankind.  He  made  many  other  advances  in  the  treat- 
ment of  diseases  of  women,  but  none  so  striking  and  complete  as  in  vesico- 
vaginal fistula.  The  silver  wire  sutures  and  the  instruments  used  by  Sims  in 
their  application,  still  hold  their  place  with  some  operators,  though  most  oper- 
ators now  prefer  the  silkworm-gut  sutures  or  buried  catgut  sutures.  In  some 
cases  the  Sims  posture  and  the  Sims  speculum  give  the  best  exposure  of  the 
field  for  operation,  but  in  most  cases  the  operation  can  be  more  quickly  and 
satisfactorily  carried  out  with  the  patient  in  the  exaggerated  lithotomy  posture, 
otherwise  known  as  the  Simon  posture. 

Steps.  After  satisfactory  exposure  of  the  fistulous  opening,  the  edges  are 
pared  as  shown  in  Fig.  500.  A  small  sharp  knife  or  curved  scissors  may  be 
used,  as  found  most  convenient.  A  very  good  plan  is  to  outline  the  area  to 
be  denuded  with  a  knife,  so  as  to  give  it  an  even  margin,  and  then  excise  the 
tissue  with  the  scissors.  The  denudation  is  made  extensive  on  the  vaginal 
surface  and  slopes  inward  toward  the  bladder  opening.  The  denudation  must 
be  carried  into  sound  tissue  so  that  primary  union  may  take  place. 

When  possible  the  denudation  should  be  made  in  such  a  way  that  the 
line  of  union  can  be  made  to  lie  somewhat  in  the  long  axis  of  the  vagina.  That 
is  preferable  for  the  reason  that  it  causes  less  disturbance  of  the  pelvic  re- 
lations. When  the  line  of  union  extends  crosswise  of  the  vagina,  the  antero- 
posterior tension  tends  to  drag  the  cervix  dowuAvard  and  cause  retroversion. 


OPERATION"   FOR   VESICO-VAGINAL   FISTULA 


571 


The  fistula  should  be  closed,  however,  in  the  way  that  will  permit  accurate 
approximation  without  injurious  tension.  In  case  the  opening  is  round,  a  V- 
shaped  denudation  may  be  made  at  each  end  to  permit  accurate  approxima- 
tion in  a  straight  line  without  too  much  tension.  If  necessary  the  edges  may 
be  brought  together  in  the  shape  of  an  X  or  a  Y. 

The  oozing  of  blood  may  be  largely  checked  by  the  application  of  a  small 
cotton  or  gauze  sponge  wrung  out  of  very  hot  water,  or  by  irrigating  with 
hot  water.     The  denudation  should  not  extend  into  the  vesicle  mucosa  as  it 


Fig.    500.     The    Regular    Operation   for   Vesico-vaginal    Fistula.      Showing   the   area    of    Denudation    and    also 
the   Deep    Sutures.      (Montgomery — Practical   Gynecology.) 


may  start  bleeding,  that  may  continue  to  prove  troublesome  even  after  the 
sutures  are  passed  and  tied.  In  some  cases,  after  such  operation,  blood  clots 
have  formed  in  the  bladder  to  such  an  extent  that  the  wound  had  to  be 
reopened. 

The  sutures  are  passed  as  shown  in  Figs.  500  and  502.  They  enter  the 
vaginal  mucosa  one-fourth  to  one-half  an  inch  from  the  margin  of  the  denuded 
area,  pass  into  the  bladder  submucosa,  emerge  near  the  bottom  of  the  de- 
nuded area  and  then  pass  through  corresponding  tissues  on  the  oj^posite  side 
of  the  Avound.     They  do  not  appear  on  the  vesical  surface. 


572 


RELAXATIOX   AXD   PISTULAE 


Tlie  sutures  are  passed  at  intervals  of  about  oue-fourtli  of  an  incli.  They 
may  consist  of  silkAvorm-gut  or  of  20-day  catgut.  After  the  sutures  are  passed 
the  bladder  should  be  washed  out  before  they  are  tied,  to  wash  out  all  blood 
from  it.  The  sutures  are  then  tied  and  cut,  and,  if  desired,  the  bladder  may 
be  filled  with  boric  acid  solution  (3%)  to  see  if  there  is  any  leakage. 

It  is  preferable  in  most  cases  to  first  close  the  deeper  portions  of  the 
wound  with  buried  sutures,  as  shown  in  Fig.  500. 

A  very  useful  expedient,  especially  when  there  is  much  loss  of  tissue  and 
decided  tension  in  bringing  the  sides  together,  is  to  incise  the  vaginal  surface 


Fig.  301.  The  Flap  Operation  for  Vesico-vaginal 
Fistula.  Making  the  Incision  for  turning  in  the  flap. 
The  "flap  operation"  is  especially  useful  where  there 
has  been  loss  of  tissue.  (Montgomery — Practical 
Gynecology.') 


Fig.  502.  The  Flap  Operation  for  Vesico-vaginal 
Fistula.  The  flap  has  been  turned  in  and  the  Deep 
Sutures  passed  and  tied.  The  Superficial  Sutures 
also  are  in  place.  If  preferred,  continuous  sutures 
may  be  used  throughout.  (Montgomerj' — Practical 
Gynecology.') 


around  the  fistula,  as  shown  in  Fig.  501,  and  then  turn  in  the  edges  without 
cutting  any  off.  The  raw  surfaces  of  the  turned-in  flaps  are  sutured  together 
by  buried  sutures  (Fig.  502)  and  then  the  vaginal  mucosa  is  closed  over  by 
continuous  or  interrupted  suture  as  desired  (Fig.  502), 

After  the  fistula  is  sutured,  a  light  packing  of  antiseptic  gauze  is  placed 


OPERATION   FOR   VESICO-VAGINAL   FISTULA  573 

in  the  vagina,  the  soft  rubber  retention  catheter  is  introduced,  if  it  is  to  be 
used,  a  dressing  is  applied  over  the  vulva  and  the  patient  is  put  to  bed. 

The  after-treatment  is  the  same  as  after  repair  of  laceration  of  the  pelvic 
floor,  with  the  addition  of  frequent  catheterization  or  constant  bladder  drain- 
age by  means  of  the  retention  catheter.  When  the  retention  catheter  is  used, 
it  is  left  in  from  three  to  eight  days,  depending  on  the  case,  and  after 
that  the  patient  urinates  or  is  catheterized  every  six  hours  until  the  wound  is 
firmly  healed. 

If  preferred,  the  bladder  may  be  emptied  by  catheter  every  three  to  six 
hours  for  the  first  two  or  three  days,  the  retention  catheter  being  thus  en- 
tirely dispensed  v.ith.  With  a  reliable  trained  nurse  in  attendance,  the  fre- 
quent catheterization  is  fairly  safe,  but  without  such  an  attendant,  the  re- 
tention catheter  is  safer.  When  it  is  used,  it  should  be  removed  and  sterilized 
each  day  and  the  bladder  washed  out  with  boric  acid  solution  (3%).  It  is 
well  to  leave  the  catheter  out  for  an  hour  or  two  for  a  change-.  As  long  as 
catheterization  is  necessary,  the  bladder  should  be  washed  out  with  boric 
acid  solution  (3%)  either  once  or  twice  daily  or  after  each  catheterization. 
When  the  retention  catheter  is  in  place,  the  patient  may  lie  in  the  prone  or 
semi-prone  posture  to  favor  drainage.  In  severe  cases  it  may  be  advisable 
to  keep  her  in  this  posture  most  of  the  time,  until  the  opening  is  healed. 

In  mild  cases,  no  special  care  is  necessary  except  to  administer  the  uri- 
nary antiseptic  and  to  see  that  the  bladder  is  emptied  every  four  to  six  hours, 
either  spontaneously  or  by  catheter. 
4       The  sutures  are  removed  in  twelve  to  fifteen  days. 

Special  Measures,  There  are  various  special  measures  required  by  special 
conditions. 

In  cases  in  which  there  are  bands  of  scar-tissue  in  the  vagina,  which  hold 
the  edges  of  the  fistula  apart,  it  is  sometimes  advantageous  to  divide  these 
Ijands  in  the  preliminary  treatment,  and  separate  the  divided  bands  widely 
hj  a  glass  plug. 

In  severe  cases,  there  is  danger  of  occlusion  of  a  ureter,  by  a  ligature  or 
by  an  opposing  surface.  This  accident  is  indicated  by  increasing  pain  in  the 
region  of  one  kidney  and  along  the  ureter,  accompanied  by  a  decided  diminu- 
tion in  the  amount  of  urine  secreted.  It  requires  the  removal  of  one  or  more 
sutures.  To  prevent  occlusion  of  the  ureter  a  eystoscopic  examination  should 
be  made  whenever  the  position  of  the  fistula  is  such  as  to  make  it  probable 
that  one  of  the  ureters  enters  it  or  lies  close  to  it.  By  eystoscopic  examina- 
tion, the  ureteral  opening  may  be  located  and,  if  it  is  dangerously  near  the 
fistula,  a  ureteral  catheter  may  be  introduced,  that  the  ureter  may  be  better 
located  during  the  operation  and  avoided. 

In  the  severer  cases,  where  there  is  much  loss  of  tissue  and  scar  contrac- 
tion, it  may  be  necessary  to  employ  one  or  more  of  the  special  measures  men- 
tioned under  recto-vaginal  fistula,  such  as  remote  incisions  of  the  vaginal 


574  EELAXATION   AND   FISTULAE 

mucous  membrane  or  transplantation  of  flaps  of  the  mucosa.    There  are  other 
special  measures  that  are  useful  in  certain  cases,  such  as  the  following : 

a.  Separation  of  the  bladder  wall  from  the  uterus  and  upper  part  of  the 
vagina,  sufficiently  to  permit  its  being  pulled  down  and  sutured  to  the  lower 
edge  of  the  opening  without  much  tension. 

b.  Drainage  of  the  bladder  by  suprapubic  cystotomy.  Satisfactory  drain- 
age can  usually  be  secured  with  a  retention  catheter  in  the  urethra.  In  cer- 
tain cases,  however,  the  neck  of  the  bladder,  and  consequently  part  of  the 
urethra,  is  in  the  damaged  area  and  is  necessarily  involved  in  the  operative 
work.  In  such  a  case,  if  a  catheter  be  left  in  the  urethra,  the  tissues  in  the 
neck  of  the  bladder  immediately  about  the  catheter,  fail  to  heal,  resulting  in 
incontinence  of  urine.  In  such  a  case,  the  bladder  may  be  drained  and  kept 
at  rest  by  suprapubic  cystotomy  and  constant  drainage.  Another  method  of 
dealing  with  these  cases  is  to  make  the  operation  in  two  stages — repairing 
first  the  urethral  injury  and  draining  the  bladder  by  the  fistula,  and  later 
closing  the  fistula  and  using  the  urethra  for  drainage. 

The  difficulties  of  operation  vary  much  in  different  cases.  A  small  vesico- 
vaginal fistula  is  easily  repaired  and  usually  heals  without  trouble.  In  the 
case  of  a  large  fistula  in  which  the  edges  can  be  easily  brought  together  with 
tenacula,  or  can  be  brought  so  near  together  that  lateral  incisions  Avill  permit 
perfect  approximation,  there  is  but  little  difficulty  for  an  experienced  oper- 
ator. It  requires  considerable  experience  in  plastic  surgery  to  be  able  to 
judge  in  some  cases  before  an  operation  whether  or  not  such  approximation 
can  be  secured.  If  it  can  not  be  secured  some  other  measure  must  be  adopted 
and  planned  for  in  detail,  before  the  day  of  operation. 

In  some  cases,  with  the  best  of  care,  two  or  three  operations  may  be  re- 
quired to  effect  a  cure,  the  fistulous  opening  being  decidedly  reduced  in  size 
with  each  operation.  But  the  operator  must  have  a  clear  understanding  of 
what  is  to  be  accomplished  in  that  particular  case  by  each  operation.  As 
Kelly  remarks  in  his  admirable  work,  "It  is  worse  than  useless  to  denude 
the  edges  of  a  large  fistula,  without  having  any  definite  idea  of  what  can  be 
accomplished  until  the  stitches  are  put  in  and  pulled  upon.  It  would  be  far 
better  to  let  the  patient  entirely  alone,  and  confess  honestly  an  inability  to 
relieve  her,  than  to  go  on  cutting  away  valuable  tissue  and  increasing  the 
size  of  the  fistula  every  time,  with  a  vague  idea  that  by  some  chance  the 
operation  may  succeed." 

'  There  are  cases  of  vesico-vaginal  fistula  presenting  a  contracted  bladder 
and  with  scar-tissue  extending  in  various  directions  binding  the  edges  of  the 
fistula  to  adjacent  bones,  that  tax  to  the  utmost  the  skill  and  ingenuity  of 
the  operator,  who  must  devise  some  way  of  bringing  the  urinary  stream 
within  control  of  the  sphincter  vesicae  and  of  providing  a  bladder-cavity 
large  enough  to  hold  a  few  hours'  urine. 


URINARY   FISTULAE 


575 


Other  Urinary  Fistulae 

Occasionally  there  occur  other  varieties  of  urinary  fistulae,  opening  into 
the  genital  tract.  There  may  be  an  opening  into  the  vagina  from  the  ureter 
of  one  or  both  sides,  or  there  may  be  an  opening  into  the  cervix  uteri  from 
the  bladder  or  from  the  ureter. 

The  usual  causes  of  these  fistulae  are  severe  laceration  of  the  cervix  in 
labor  or  some  operation  at  the  vaginal  vault.  The  fistula  appears  as  a  small 
opening  in  the  scar-tissue,  from  which  urine  escapes.  If  due  to  injury  dur- 
ing operation,  the  injury  may  have  been  caused  by  a  tear  of  the  bladder  wall 
while  separating  it  from  the  uterus,  by  a  bite  of  a  ureter  or  the  bladder  by 
the  tip  of  a  pressure  forceps,  by  a  puncture  of  a  ureter  or  the  bladder  by  a 
ligature  carrier,  or  by  inclusion  of  a  ureter  in  a  ligature. 

When  due  to  an  injury  during  labor,  the  vesico-uterine  fistula  is  caused 
by  a  severe  laceration  of  the  cervix  extending  up  into  the  vaginal  vault  and 
through  the  bladder  wall.  The  lower  portion  of  the  cervical  womid  heals, 
but  the  upper  part  communicating  with  the  bladder  fails  to  heal,  and  there  is 
left  an  opening  from  the  bladder  into  the  cervical  canal. 

In  the  ureteral  fistulae,  if  one  ureter  only  is  involved,  there  will  be  leak- 
ing of  urine  into  the  vagina  and  at  the  same  time  urine  from  the  other  ureter 
will  be  received  and  contained  in  the  bladder  and  passed  normally.  If  both 
ureters  are  involved,  all  the  urine  will  pass  into  the  vagina  and  none  into  the 
bladder.  In  either  case,  if  methylene-blue  solution  be  injected  into  the  blad- 
der, none  of  it  will  pass  through  into  the  vagina.  When  the  fistula  is  con- 
nected with  a  ureter,  the  urine  comes  in  little  gushes  at  intervals  of  several 
seconds. 

The  vesico-uterine  and  uretero-uterine  fistulae  are  indicated  by  the 
escape  of  urine  from  the  cervical  canal.  Colored  water  injected  into  the  blad- 
der comes  out  of  the  cervical  canal  if  the  fistula  is  connected  with  the  blad- 
der, but  not  if  it  is  connected  with  the  ureter. 

These  fistulae  at  the  vault  of  the  vagina  often  close  spontaneously  after 
a  few  w-eeks,  the  vagina  in  the  meantime  being  kept  clean  by  frequent  anti- 
septic douches.  If  a  fistula  persists  after  several  weeks  with  no  apparent 
prospect  of  closing,  it  will  be  necessary  to  close  it  by  operation.  Occasionally 
the  fistula  may  be  closed  by  a  small  operation,  for  example,  in  the  vesico- 
uterine fistula  if  the  fistula  is  near  the  free  margin  of  the  cer^dx,  the  cervix 
may  be  split  up  to  the  fistula,  the  infiltrated  margins  of  the  fistula  excised, 
and  the  whole  area  closed,  much  the  same  as  an  ordinary  cervical  laceration, 
with  the  addition  of  a  few  extra  sutures  for  the  bladder  Avail.  If  the  fistulous 
tract  is  situated  high  in  the  cervix  the  operation  will  involve  separation  of 
the  bladder  from  the  uterus  and  separate  closure  of  the  two  wounds.  This 
may  be  carried  out  through  vaginal  dissection  or  by  abdominal  section,  as 
found  most  convenient.  The  majority  of  fistulae  at  the  vaginal  vault  require 
rather  extensive  operative  procedures,  vaginal  or  abdominal  (depending  upon 


576  RELAXATION    AND   FISTULAE 

the  character  and  location  of  the  fistula),  and  in  most  cases  the  procedures 
can  be  carried  out  satisfactorily  only  by  one  familiar  "\^-ith  pelvic  and  abdom- 
inal operative  work.  Occasionally  nephrectomy  is  advisable,  to  stop  the  con- 
tinuous leakage  of  urine  from  a  ureteral  tistula  that  can  not  be  repaired. 

Destruction  of  Urethra 

The  condition  referred  to  here  is  destruction  of  the  urethra  by  ulcera- 
tion beginning  in  the  vestibule  and  extending  upward  to  the  bladder.  The 
urethra  is  destroyed  as  far  as  function  is  concerned  and  there  remains  simply 
an  opening  from  the  bladder  to  the  external  genitals,  through  which  the  urine 
constantly  dribbles. 

The  destructive  ulceration  usually  is  syphilitic.  The  treatment  is  to  re- 
store the  urethra  by  a  plastic  operation.  The  cases  often  prove  very  rebel- 
lious to  operative  treatment,  it  being  particularly  difficult  to  secure  restora- 
tion of  the  sphincter  function.  The  cause,  course  and  effective  treatment  of 
this  troublesome  affection  are  given  in  detail  in  a  paper*  read  by  the  author 
before  the  St.  Louis  Obstetrical  and  Gynecological  Society. 

Partial  Incontinence  of  Urine 

Some  patients  complain  of  inability  to  control  the  urine  when  coughing, 
laughing,  etc.  In  others  the  urine  escapes  Avhen  the  bladder  reaches  a  certain 
fullness.  Patients  past  the  menopause  may  find  difficulty  in  retaining  the 
*  urine  when  weakened  by  sickness  or  when  very  tired. 

The  incontinence  is  due  to  weakness  of  the  sphincter  vesicae.  This  weak- 
ness is  due  in  most  cases  to  stretching  and  injury  at  childbirth.  The  tissues  in 
front  of  the  vaginal  opening  are  usually  stretched  considerably  during  childv 
birth  and  in  some  cases  very  much.  Ordinarily  this  stretching  is  recovered 
from  sufficiently  to  restore  complete  control,  though  the  urethra  is  usually 
larger  than  before.  In  some  cases  the  tone  of  the  sphincter  is  not  recovered 
and  consequently  there  is  not  complete  control  of  the  urine.  In  some  cases, 
though  the  tone  is  not  fully  recovered,  the  patient  is  able  to  control  the  urine, 
until  the  muscular  atrophy  of  old  age  comes  on.  It  is  the  latter  factor  that 
.makes  this  of  such  frequent  occurrence  in  the  aged. 

The  treatment  is  to  strengthen  the  sphincter  vesicae.  This  is  accom- 
plished by  excising  a  wedge-shaped  piece  of  tissue  in  the  region  of  the 
sphincter  vesicae.  This  includes  vaginal  wall  and  underlying  tissues  but 
should  not  extend  into  the  urethral  canal.  The  tissues  are  then  brought  to- 
gether and  piled  up  by  sutures,  buried  and  otherwise.  In  many  of  these  cases 
there  is  also  cystocele  and  relaxed  pelvic  floor,  both  of  which  conditions  should 
be  thoroughly  repaired,  extra  buried  sutures  being  passed  in  the  region  of 
the  sphincter  vesicae.  In  inoperable  cases,  relief  may  sometimes  be  given  by  a 
specially  adjusted  pessary. 

*A  Vesico-Vaginal  Opening  as  a  Means  of  Bladder  Drainage  in  Extensive  Plastic  Work  on  the 
Urethra,    by   H.    S.    Crossen,    M.D.      American    Journal    of    Obstetrics,    1899. 


CHAPTER  VI 

DISEASES  OF  THE  UTERUS 

POINTS  IN  ANATOMY 

The  uterus  is  situated  about  the  center  of  the  pelvic  cavity,  between  the 
bladder  and  the  rectum  (Figs.  1,  3,  582).  It  projects  upward  into  the  lower 
part  of  the  peritoneal  cavity,  and  its  convex  surface,  except  the  lower  portion, 
is  enveloped  by  peritoneum.    The  upper  end  of  the  uterus  is  directed  forward. 


Reflection  of 
feritoneum. 


Fig.   503.     Anterior   View   of   the   Ijterus.      (Dickin- 
son— American   Textbook   of   Obstetrics.) 


Fig.  504.     Antero-posterior     Section     o£    Uterus, 
showing    walls    and    cavity.       (Dickinson — American 
Textbook   of   Obstetrics.) 


The  lower  end  is  directed  backward  and  downward  and  projects  into  the  up- 
per end  of  the  vagina.  The  uterus  is  freely  movable,  especially  the  upper 
portion,  and  may  be  pushed  backward  by  a  full  bladder  or  forward  by  a  full 
rectum. 

The  uterus  is  shaped  somewhat  like  an  inverted  pear  (Figs.  503,  504,  505). 
Its  lower  constricted  portion  is  called  the  cervix  uteri  (neck  of  the  uterus) 
and  to  this  the  vagina  is  attached.  The  remainder  of  the  organ  is  called  the 
corpus  uteri  (body  of  the  uterus).  It  is  from  the  upper  portion  of  the  uterus, 
the  widest  portion,  that  the  Fallopian  tubes  arise.  That  portion  of  the  uterus 
lymg  above  the  Fallopian  tubes  is  known  as  the  fundus  uteri  (Fig.  505). 

The  uterus  has  a  small  central  cavity  (Figs.  505,  506)  which  is  lined  Avith 
mucous  membrane  and  which  communicates  through  the  vagina  with  the 
outside  world  and  through  the  Fallopian  tubes  with  the  peritoneal  cavity 

577 


578 


DISEASES   OF    THE   UTEEUS 


(Fig.  658).  This  is  the  only  continuous  opening  from  the  outside  of  the  body 
into  the  peritoneal  sac,  and  it  is  because  of  this  direct  opening  into  the  peri- 
toneal cavity  that  peritonitis  is  so  much  more  frequent  in  women  than  in  men. 


longitudinal  duct  of  epoophoron     of  epocphomi 


mesosalpinx 


fundus  of  uterus 


uterine  orifice 
of  tube^ 


serous 
coat 

body  oj  lUcni 


niuscuiiir    '  •  ^  -■ 
coat  \ 

mucous  coat  '" '' 


supravanincil 
portion  of  cervix 


vaginal  portion,-  C- 
of  cervix 


plicae  isthniicae 

uterine  portion 

of  tuba        isthmus 


nmpuUa  of  tuba  ntcrina 


,  plicae  ampul- 
-ri       lares 


'■  infundibulum 

.    fimbria  ovanca 

appendix 

ovarian  ligament  f     ^^,^.^;  ,  vesiculosa 

cavity,  of  uterus  mesovarian       'folliculi  vesiculosi 

border  of  ovary 


canal  of  cervix 
plica  palinata 


external  os  uteri 
I  spinal  rugae 

posterior  column  of  rugae 

body  of  uterus 


supravaginal  portion 
of  cervix 


fundus  of  uterus 


anterior  tiii^'% 


cavity  of  uterus 


_^      canal  of  cervix 


(- posterior  fornix 

~~-     of  vagina 


bosterior  lip 


inal  portion  of  cerK 


Fig.  505.  The  Uterus  and  the  Right  Fallopian  Tube  and  the  Right  Ovary,  laid  open.  View  from 
behind.  In  the  right  lower  corner,  an  Antero-posterior  Section  of  the  Uterus  is  shown.  (Sobotta  and 
McMurrich — Human  Anatomy.') 

The  size  of  the  uterus  is,  of  course,  different  in  the  different  periods  of 
life  (Figs.  507,  508,  509).     At  birth  it  is  a  trifle  over  one  inch  long  and  the 


POINTS   IN   ANATOMY 


579 


cervix  comprises  two-thirds  of  the  organ  (Fig.  510).  It  is  important  to  keep 
in  mind  the  peculiarities  of  the  infantile  uterus,  for  occasionally  an  adult 
presents  a  uterus  somewhat  infantile  and  accompanied  wdth  troublesome 
symptoms  due  to  lack  of  development.  A  rather  common  condition  and  a 
very  troublesome  one  (see  dysmenorrhea)  is  a  sharp  anteflexion  of  the  cervix 
-^-the  corpus  uteri  being  in  practically  normal  position,  but  the  cervix  being 


.^^ 


-'-.-.    J> 


Fig.   507.     Uterus    and    Appendages    of    a    Young    Child. 
(Williams — ObstetrKs.) 


Fig.    506.  Reconstruction    of    the 

uterus,  showing  the  shape  of  the  cavity. 
(Williams — Obstetrics.) 


Fig.   508.     Uterus    and    Tube    and    Ovary    of    a    Fourteen- 
year-old   Girl.      (Williams — Obstetrics.) 


r 


Fig.   509.     Uterus    and    Tube    and    Ovary    of    a    Twenty-year-old    Multipara.       (iWilUams—Obstetrics.) 

flexed  sharply  for^^^ard  and  directed  along  the  vaginal  canal  toward  the 
opening.  In  the  fetus,  the  uterus  lies  very  high  and  the  cervix  is  very  long. 
At  first  the  axis  of  the  cervix  lies  almost  in  the  axis  of  the  vagina,  as  shown 
m  Fig.  510.  Normally,  as  development  progresses,  the  corpus  uteri  gradu- 
ally comes  forward   and  the   cervix  becomes  directed  somewhat   backward, 


580 


DISEASES   OF    THE   UTERUS 


Fig.   SIO.     Vertical    mesial     section     of    the    pelvis     of    a    large    fetus    at    time     of    birth. 
(Webster — Diseases    of    Women.) 


Fallopuzn 
tube 

Round 
Liqanwnt 


Body  of  Utei'us 
Isthrrms 


Extra.  Vaqincd 
portion  of  Cervix. 

Externcd  as 


Posterior  Wcdl  of 
Vccffino/. 

Fig.  511.     A    Comparison    of    the    Nulliparous    Uterus    with   the    Multiparous    Uterus. 
(Edgar — Practice    of    Obstetrics.) 


POINTS   IN   ANATOMY 


581 


across  the  vaginal  axis.  In  the  eases  of  imperfect  development  above  re- 
ferred to,  the  corpus  uteri  comes  forward  normally  but  the  cervix  fails  to  as- 
sume its  backward  direction — remaining  in  practically  the  fetal  position  (di- 
rected along  the  axis  of  the  vagina)  and  causing  a  sharp  ''anteflexion  of  the 
cervix"  (Fig.  311). 

The  adult  virgin  uterus  is  three  inches  long   (cavity  two  and  one-half 
inches)  and  the  cervix  forms  one-third  of  the  organ.    The  transverse  measure- 


^T^  PoRTiofy 


^  iNTEJ^MEtfE, 
^  PoF^TIOfir 

V/ICINAL 


Fig.  512.     Showing  the   Relations  of  the  Uterus  to  the  Vagina  and  Bladder  and   Peritoneum. 
(Dickinson — American  Textbook   of  Obstetrics.) 


i'-'i^-S^-^S-  «>^ir-^S 


Fig.   513.      Endometrium    of    an    infant,    just    born.       (Williams — Obstetrics.') 


ment  at  the  widest  part  is  one  and  a  half  to  two  inches,  and  the  average  thick- 
ness is  one  inch.  It  w^eighs  an  ounce  to  an  ounce  and  a  half.  After  childbirth 
the  uterus  is  always  a  little  larger  than  the  virgin  uterus  (Fig.  511).  This 
is  the  kind  most  frequently  requiring  examination.  The  cavity  measures  two 
and  one-half  to  three  inches.  After  the  menopause  there  is  marked  atrophy 
of  all  the  genital  organs,  including  the  uterus.  The  extent  of  the  atrophy  of 
the  uterus  is  variable.  In  the  very  aged  it  may  be  reduced  to  a  nodule  the 
size  of  the  end  of  the  thumb,  and  the  cervix  then  no  longer  projects  into  the 


582  DISEASES   OF    THE    UTERUS 

vaginal  cavity,  but  is  felt  simply  as  an  indurated  area,  with  a  small  central 
opening,  situated  in  the  upper  part  of  the  anterior  vaginal  wall. 

Structure  of  the  Uterus 

The  uterus  is  a  hollow  muscle.  The  central  cavity  is  lined  with  mucous 
membrane  while  the  external  surface  of  the  muscle  is  covered  with  perito- 
neum. The  wall  of  the  uterus  is,  therefore,  composed  of  three  layers — perito- 
neal, muscular,  and  mucous  (Figs.  504,  505). 

1.  Peritoneal  Layer.  This  forms  a  delicate  serous  covering  to  the 
uterus.  It  does  not  ditfer  materially  from  peritoneum  elsewhere.  There  are 
certain  portions  of  the  uterus  which  are  not  covered  by  peritoneum,  namely, 
the  lateral  portions  of  the  body  and  the  front  and  sides  of  the  cervix  (Fig. 
512). 

2.  Muscular  Layer.  This  is  the  real  wall  of  the  uterus.  It  is  one-half  to 
three-fourths  of  an  inch  thick  and  is  composed  of  involuntary  muscular  tis- 
sue. Under  the  microscope,  the  principal  elements  are  seen  to  be  the  long 
muscle  cells.  They  are  fusiform  in  shape  and  are  arranged  in  parallel  rows. 
These  rows  of  muscle  cells  are  arranged  in  bundles  that  extend  in  various 
directions. 

The  muscular  wall  of  the  uterus  is  divided  somewhat  into  strata.  In  the 
unimpregnated  uterus,  the  different  strata  are  not  clearly  defined,  but,  speak- 
ing in  a  general  way,  it  may  be  said  that  the  muscular  bundles  are  arranged  in 
three  strata — a  thin  outer  longitudinal  stratum,  a  thick  middle  stratum  of 
interlocking  bundles  extending  in  various  directions,  and  a  thin  inner  longi- 
tudinal stratum. 

The  connective  tissue  of  the  muscular  layer  comprises  most  of  the  con- 
nective tissue  of  the  uterus.  It  is  not  distributed  in  the  form  of  distinct  strata, 
but  appears  as  irregular  masses  surrounding  and  supporting  the  important 
elements.  There  is  a  very  intimate  connection  between  the  mucous  membrane 
lining  the  uterus  and  the  connective  tissue  of  the  muscular  layer. 

The  blood  vessels  of  the  muscular  layer  include  most  of  the  vessels  of 
the  uterine  wall.  The  arteries  are  distinguished  in  a  microscopic  section,  by 
their  thick  walls  and  folded  intima.  The  outer  vessels  run  in  a  longitudinal 
direction,  while  the  inner  vessels  run  perpendicular  to  the  mucous  surface. 
There  is  a  dense  capillary  network  close  to  the  mucous  membrane. 

The  veins  are  very  large  and  have  thin  walls. 

The  lymphatics  of  all  the  coats  of  the  uterus  (peritoneal,  muscular,  and 
mucous)  empty  into  large  lymphatic  vessels  in  the  external  muscular  stratum. 
These  in  turn  empty  into  efferent  trunks  at  the  sides  of  the  uterus. 

The  nerves  of  the  muscular  layer  are  derived  from  the  sympathetic. 
The  filaments  ramify  among  the  muscular  bundles  and  terminate,  in  the  nuclei 
of  the  muscle  cells. 

3.  Mucous  Laver.     The  mucous  membrane  of  the  uterus  lies  directly  on 


POINTS   IN   ANATOMY 


583 


the  internal  muscular  stratum,  the  usual  submucous  layer  of  loose  connective 
tissue  being  absent.  Scattered  muscular  filaments  extend  into  the  mucosa, 
so  the  connection  between  the  two  is  firm.  The  mucous  membrane  of  the  body 
of  the  uterus  is  known  as  the  ''endometrium."  That  lining  of  the  cervix  is 
kno^'VT.i  as  the  "cervical  mucosa." 

The  endometrium  is  about  14.5  of  an  inch  thick  in  the  child-bearing  period, 
and  is  disposed  over  the  interior  of  the  uterus  as  a  smooth  layer  (Figs.  505, 
551).  It  is  soft  and  velvety  to  the  touch,  and  when  perfectly  fresh  has  a  pink 
color.  Most  of  the  specimens  seen  some  hours  after  removal  of  the  uterus 
have  a  grayish  appearance,  indicating  a  beginning  postmortem  change.  There 
is  a  great  difference  in  the  thickness  and  general  appearance  of  the  endo- 
metrium in  the  different  periods  of  life.  The  endometrium  of  the  newborn 
infant  is  shown  in  Fig.  513,  in  childhood,  in  Figs.  514,  515;  in  adult  life 


Fig.    514. 


Microscopic  section  of  uterine  wall 
of    child,    aged    8    years. 


Fig.   515.     Same  section   as   shown   in  Fig.    514, 
under    higher    power. 


f child-bearing  period),  in  Figs.  516,  517;  and  after  the  menopause  in  Fig.  520. 
The  basis  of  the  endometrium  is  a  tissue  composed  almost  exclusively  of 
oval  cells,  somewhat  larger  than  a  leukocyte  and  having  a  round  or  oval 
nucleus  that  stains  lightly.  The  nucleus  is  so  large  that  it  occupies  most  of 
the  cell.  When  stained  it  is  reticular,  i.  e.,  it  shows  the  chromatin  bands  and 
does  not  stain  a  solid  dark  color  as  does  the  nucleus  of  a  lymphocyte.  These 
oval  cells  with  the  large  reticular  nucleus  are  known  as  stroma  cells.  They 
are  packed  closely  together,  with  nothing  separating  them  except  a  few  cell 
processes  and  a  small  amount  of  serous  or  mucoid  intercellular  substance. 
The  tissue  thus  formed  is  known  as  cytogenic  tissue.  When  a  specimen  of  it  is 
stained,  the  microscopic  field  seems  to  be  almost  entirely  occupied  by  rounded 
or  oval  reticular  nuclei  (Fig.  517).  The  cell  protoplasm  stains  so  lightly  and 
is  so  small  in  amount  that  it  is  scarcely  noticeable.     The  stroma  cells  may 


584 


DISEASES   OF    THE   UTERUS 


vary  slightly  in  size  and  shape,  but  any  general  change  to  a  marked  degree  in 
size  or  shape,  means  some  disease.  There  are  normally  no  connective  tissue 
fibers  or  muscle  fibers  or  vessels  with  well-marked  walls,  in  the  cytogenic  tissue 
near  the  free  surface  of  the  mucosa,  though  all  these  may  appear  in  certain 
abnormal  conditions. 

The  free  surface  of  the  endometrium  is  covered  with  a  layer  of  ciliated 
columnar  epithelial  cells  (Fig.  513).  These  have  a  large  reticular  nucleus, 
situated  near  the  center  of  the  cell  but  a  little  closer  to  the  attached  end  than 
to  the  free  end.  The  cilia  are  not  seen  in  the  ordinary  preparation  but  come 
out  well  in  Fig.  517. 

The  endometrium  contains  many  glands.     These  are  simply  tubular  de- 


"  » 

■ -"■'^^^^Pj'^^^fell 

'^^^•'                              ' 

,^^"               ' 

/    ^  ^  -% 

_^,-, . 

Fig.  516.     Practically    Normal    Adult    Endometrium. 

pressions  of  the  lining  epithelial  layer  (Fig.  514,  and  especially  Fig.  515). 
The  epithelial  cells  lining  the  glands  present  the  same  general  characteristics 
as  the  cells  on  the  surface  of  the  endometrium  (Fig.  516).  The  glands  are 
formed  by  infolding  of  the  epithelial  lining  of  the  endometrium.  At  puberty 
they  increase  in  number  and  at  each  menstrual  period  they  increase  slightly 
in  length  (Figs.  518,  519). 


Normal  Changes  in  the  Endometrium 

The  structure  of  the  endometrium  undergoes  normal  changes  due  to  men- 
struation, to  pregnancy  and  to  the  menopause. 

Menstruation.     During  menstruation  the  endometrium  becomes  engorged 


POINTS   IN   ANATOMY 


585 


with  blood,  and  this,  with  some  slight  hypertrophy,  is  essentially  all  the  change 
there  is.  The  marked  growth  of  the  endometrium  followed  by  its  wholesale 
disintegration,  which  was  formerly  supposed  to  take  place,  has  been  found 
not  to  occur  normally.  There  is  simply  marked  engorgement,  which  comes 
on  rather  slowly  and  disappears  slowly.  As  a  result  of  this  engorgement  the 
endometrium  becomes  much  swollen  and  there  is  extravasation  of  blood  into 
the  stroma,  among  the  stroma  cells  (Figs.  518,  519).    From  there,  part  of  it 


s*^t 


g>  =-^i 


Fig.   517.     A  Microscopic   Section   of  the   Endometrium,   showing  the    Stroma   Cells   and  also   a   cross  section 
of  a  Gland.      The   structures   are   magnified   420   times.      (Williams — Obstetrics.') 


finds  its  way  into  the  glands  and  then  into  the  cavity  of  the  uterus,  while 
another  part  of  it  passes  directly  through  the  surface  epithelial  layer  into  the 
cavity.  This  extravasation  of  blood  interferes  somewhat  with  the  nutrition 
of  the  epithelium  in  small  areas  and  the  epithelium  is  thrown  off  over  these 
areas  (Fig.  519)  and  appears  in  the  menstrual  discharge  as  single  cells  or  as 
groups  of  cells.  There  may  occasionally  be  a  small  piece  of  stroma  cast  off, 
but  there  is  no  disintegration  of  any  considerable  portion  of  the  endometrium, 


586 


DISEASES    OF    THE   UTERUS 


as  formerly  supposed.  In  many  cases  of  ordinary  dysmenorrhea,  small  pieces 
of  the  endometrium  are  cast  off,  but  these  changes  are  abnormal,  as  are  also 
the  cases  of  marked  '^ dysmenorrhea  membranacea."    After  menstruation  the 


,re  ..^    *      '-• 


,\      <,  •;'f\^'/-i?^' 


It*  5,  <^'  TV. 


Fig.   518.     Menstruating    Endometrium.      Early    Stage. 


Fig.  519.     Menstruating   Endometrium.     Notice    (a)    flood  in   the   tissues,    (b)    surface    denuded   of 
epithelium,   irregular   and   covered   with    debris    and    (c)    cork-screw   glands. 


extravasated  blood  which  has  not  passed  into  the  cavity  is  absorbed  from  the 
stroma  together  with  the  remnants  of  those  stroma  cells  that  have  been  so 
damaged  that  they  disintegrate.    In  a  few  days  the  endometrium  has  returned 


POINTS   IN"   ANATOMY 


587 


to  its  normal  resting  condition.  Menstruation  as  a  function,  is  considered  in 
detail  in  Chapter  xiv. 

Pregnancy.  The  changes  in  structure  due  to  pregnancy  are  marked  and 
exceedingly  interesting,  but  a  description  of  them  would  be  out  of  place 
here. 

Menopause.  At  the  menopause  the  senile  change  begins  to  be  manifest. 
This  is  essentially  an  atrophy  of  the  cytogenic  tissue  and  of  the  glands,  with 
the  development  of  fibrous  tissue  throughout  the  endometrium,  hyaline 
changes  in  the  vessels  and  finally  loss  of  the  surface  epithelium,  so  that  the 
endometrium  comes  to  resemble  scar-tissue   (Fig.  520).     This  process  extends 


Fig.  520.  Senile  Endometrium  of  a  woman,  aged  62  years.  Glandular  tissue  has  practically _  dis- 
appeared. The  very  thin  layer  of  endometrial  tissue  lying  over  the  muscle  is  covered  by  a  single 
layer   of   cubical    cells. 


over  several  years  and  may  be  encountered  in  any  stage  of  development. 
Many  senile  uteri  present  conditions  very  different  from  the  normal  ones  here 
mentioned,  but  those  different  conditions  are  due  to  pathologic  processes  and 
not  to  senility. 

Peculiarities  of  the  Cervix  Uteri 

The  structure  of  the  cervix  differs  from  that  of  the  body  of  the  uterus 
in  several  particulars,  as  f oUoavs  : 

a.  The  greater  part  of  the  cervix  has  no  peritoneal  covering  (Fig.  512). 

b.  The  muscular  layer  of  the  cervix  has  a  much  larger  proportion  of 
connective  tissue  and  hence  is  much,  firmer. 


588 


DISEASES   OF    THE   UTERUS 


c.  There  are  no  large  venous  sinuses  in  the  cervix  and  the  blood  vessels 
have  thicker  walls  and  smaller  lumina  than  those  of  the  body  of  the  uterus. 

d.  The  mucous  membrane  lining  the  cervix  (cervical  mucosa)  is  disposed 
in  prominent  folds  (Fig.  505).    These  folds  extend  more  or  less  obliquely  out- 


Fig.  521.  Longitudinal  section  of  a  Gland  of  the 
Cervix.  This  is  evidently  taken  from  near  the  ex- 
ternal OS,  as  the  squamous  epithelium  extends  up  to 
it.  A  cross  section  of  part  of  a  gland  is  shown  at 
thtf  lower  margin.     (Cullen — Cancer  of  the  Uterus.) 


*"-  V>"a  ■*•*>  ■'.>»"    U 


Fig.   522.     Cross    section    through    a    practically 
normal  cervical  gland.     Photomicrograph,  high  power. 


ward  from  two  ridges,  one  situated  near  the  center  of  the  posterior  lip  and 
the  other  near  the  center  of  the  anterior  lip. 

e.  The  glands  of  the  cervix  approach  the  racemose  variety.  They  consist 
of  branching  ducts  with  dilated  ends  (Figs.  521,  522).  The  glands  are  lined 
Avith  columnar  epithelial  cells  Avhich  are  even  taller  than  those  on  the  sur- 
face. The  nucleus  of  each  cell  lies  at  the  base.  These  cells  secrete  mucus 
which  does  not  stain  appreciably  in  ordinary  preparations  (hematoxylin  and 


POINTS   IN    ANATOMY 


589 


€Osin),  consequently  that  portion  of  the  cell  lying  next  to  the  lumen,  which 
part  of  the  cell  is  usually  filled  with  mucus,  appears  clear  (Fig.  522). 

The  glands  of  the  cervix  secrete  a  clear  viscid  tenacious  mucus  that  fills 
the  cervical  canal  and  serves  to  close  it  and  prevent  invasion  of  the  uterine 
<3avity.  The  ducts  of  these  glands  sometimes  become  obstructed  causing 
retention  cysts   (Fig;  518).     These  are  sometimes  called  ''ovulae  Nabothi." 

Sup  ves. 

i    Hypogastric 


Tube  <■ 

Fig.   523.     The    Blood    Supply    of   the    Uterus.      Showing    the   Uterine    Artery    as    it    leaves    the    anterior 
trunk    of    the    internal    iliac.       (Kelly — Operative    Gynecology.) 

There  may  be  many  of  them,  in  which  case  the  cervix  is  said  to  be  in  a  state 
of  ''cystic  degeneration"  (Figs.  539,  541). 

f.  The  layer  of  cytogenic  tissue  with  characteristic  stroma  cells,  is  com- 
paratively thin  in  the  cervix. 


590 


DISEASES   OF    THE   UTERUS 


g.  The  cervical  mucosa  does  not  take  part  in  the  changes  of  menstrua- 
tion or  pregnancy,  except  in  rare  cases.  It  does,  however,  undergo  the  atrophy 
of  senility,  but  here  the  change  is  not  so  marked  as  in  the  endometrium  for 
the  cytogenic  tissue  is  not  so  abundant. 

Vessels  and  Nerves  of  the  Uterus 

The  blood  supply  of  the  uterus  comes  from  the  uterine  and  ovarian  ar- 
teries. The  uterine  artery  of  each  side  arises  from  the  anterior  trunk  of  the 
internal  iliac  (Fig.  523)  and  passes  inward  and  downward  between  the  layers 


Fig.   524.     The    Blood    Supply    of    the   Uterus.      Showing   the    course    of    the    uterine    artery   along    the    side 
of  the  uterus.     The  ovarian  vessels  also  are  shown.      (Kelly — Operative   Gynecology.) 

of  the  broad  ligament  to  just  above  the  lateral  vaginal  fornix.  It  then  turns 
upward  and  runs  in  a  very  tortuous  course  along  the  side  of  the  uterus. 
Near  the  top  of  the  uterus  it  joins  the  descending  branch  of  the  ovarian 
artery  (Fig.  524). 

As  it  runs  along  the  side  of  the  uterus,  the  uterine  artery  gives  off  many 
branches  which  run  horizontally  about  the  organ  and  supply  various  seg- 
ments.   These  anastomose  with  corresponding  branches  of  the  opposite  artery. 


POINTS   IN   ANATOMY 


591 


These  branches  are  very  tortuous,  the  tortuous  and  spiral  arrangement  bemg^ 
so  marked  that  they  have  been  called  the  ''curling  arteries"  of  the  uterus.  A 
horizontal  branch  of  considerable  size  at  the  level  of  the  internal  os  is  known 
as  the  "circular  artery." 

The  ovarian  artery  of  each  side  supplies  the  tube,  and  ovary  and  upper 
part  of  the  uterus.  They  correspond  to  the  spermatic  arteries  in  the  male  and 
arise  directly  from  the  aorta.  The  artery  of  each  side  passes  downward  and 
enters  the  broad  ligament.  After  giving  off  the  branches  that  supply  the 
ovary,  the  artery  passes  on  to  the  upper  part  of  the  uterus  where  it  divides 
into  two  branches.  The  upper  branch  supplies  the  fundus  uteri  and 
anastomoses  with  the  corresponding  branch  of  the  opposite  artery.    The  lower 


Kjmry.  -^'^S'"'"'^"'  Lymphatics  of  body  and  fundus. 


Lymphatics 

from  the  body 

passing  to 

lumbar 

glands. 

Lymphatics 

of 

Fallopian 

tube. 

Lymphatics 

of 

Fallopiafi 

tube. 


Lymphatic 
fiug. 


Lymphatics 
cf  cervix. 


Lymphatics 

fromlhe  body 

passing  to 

lumbar 

glands. 


-     Fallopian^ 
tube. 


Vagina. 


Fig.  525.  The  Lymphatics  of  the  Uterus.  The  collection  of  the  lymphatic  vessels  of  each  side 
into  two  groups,  one  from  the  cervix  uteri  and  the  other  from  the  corpus  uteri,  is  well  shown.  (Poirier — 
The  Lymphatics.) 


and  larger  branch  descends  along  the  side  of  the  uterus  and  anastomoses  with 
the  uterine  artery.  Some  authorities  describe  the  uterine  artery  as  supplying 
all  of  the  side  of  the  uterus  and  a  part  of  the  tube,  and  anastomosing  with  the 
ovarian  artery  some  distance  out  along  the  tube.  Possibly  the  distribution, 
differs  considerably  in  different  individuals. 

The  veins  of  the  uterus  are  exceedingly  numerous.  The  organ  is  sur- 
rounded by  a  vast  network  of  these  vessels,  which  receive  the,  blood  from  the 
veins  and  sinuses  within  its  walls.  There  is  free  communication  of  these 
plexus  with  the  vaginal  and  vesical  plexus  below  and  with  the  ovarian  (pam- 
piniform) plexus  above,  the  blood  ultimately  emptying  into  the  internal  iliac 
vein. 


592 


DISEASES   OF    THE   UTERUS 


Fig.   526.     The    Distribution   of   the   Ivymphatics    of   the   Uterus   to    the   various    Groups    of    Glands. 
(Doederlein  and   Kroenig^ — Operative   Gynaekologie.) 


POINTS   IN   ANATOMY  593 

All  important  fact,  from  a  surgical  standpoint,  is  that  in  the  median  line 
the  uterus  is  almost  free  of  blood  vessels — so  much  so  that  it  may  be  bi- 
sected (as  is  frequently  done  in  vaginal  hysterectomy)  with  but  little  hemor- 
rhage. 

The  lymphatics  of  the  uterus  may  be  divided  into  two  groups,  the  lym- 
phatics of  the  cervix  and  the  lymphatics  of  the  body  of  the  uterus,  as  sho^vn 
in  Fig.  525.  The  lymphatics  of  the  cervix  uteri  join  with  those  of  the  upper 
part  of  the  vagina  and  empty  into  the  sacral  and  hypogastric  and  superior 
iliac  glands.  The  lymphatics  from  the  corpus  uteri  join  with  those  of  the 
tube  and  ovary  and  empty  into  the  lumbar  glands.  A  few  lymphatics  from 
the  uterine  cornua  pass  along  the  round  ligaments  and  empty  into  the  in- 
guinal glands.  The  distribution  of  the  uterine  lymphatics  to  the  various 
glands  is  sho^^ai  in  Fig.  526. 

The  nerves  of  the  uterus  are  derived  from  the  hypogastric  plexus  of  the 
sympathetic  and  from  the  third  and  fourth  sacral  nerves  of  the  central  nerv- 
ous system. 

Ligaments  of  the  Uterus 

The  uterus  is  held  in  its  position  by  the  pelvic  floor  and  by  certain  liga- 
ments (Fig.  527).  The  ligaments  are  eight  in  all,  four  on  each  side.  They 
are  the  broad  ligaments,  the  round  ligaments,  the  sacro-uterine  ligaments 
and  the  vesico-uterine  ligaments. 

The  vesico-uterine  ligaments  are  simply  folds  of  peritoneum  extending 
from  the  uterus  to  the  bladder,  as  shown  in  Fig.'^^^Or*  S  "^  ^ 

The  sacro-uterine  ligaments  are  similar  folds  of  peritoneum  extending 
from  the  uterus  around  the  rectum  to  the  sacrum  (Figs.  4  and  527).  They 
contain  also  some  fibrous  tissue  and  a  few  muscular  fibers,  hence  they  are 
stronger. 

The  round  ligament  of  each  side  is  a  fibromuscular  cord  which  arises  from 
the  top  of  the  uterus  just  in  front  of  the  Fallopian  tube  and  extends  outward 
and  forward  in  the  upper  part  of  the  broad  ligament  to  the  internal  inguinal 
ring  (Figs.  5  and  527).  It  then  passes  through  the  inguinal  canal  and  at  the 
external  ring  divides  into  fibrous  filaments  which  are  lost  in  the  tissues  cov- 
ering the  pubic  joint  (Fig.  5).  The  round  ligaments  are  four  or  five  inches 
in  length  and  tend  to  prevent  marked  backward  displacement  of  the  uterus. 
Ordinarily  they  are  lax  but  when  the  uterus  is  displaced  backwards  by  a 
full  bladder  or  other  condition,  they  are  made  tense  and  help  to  bring  the 
uterus  back  to  its  accustomed  position.  It  is  the. round  ligaments  that  are 
shortened  in  certain  operations  for  the  cure  of  backward  displacement  of  the 
uterus. 

The  broad  ligament  of  each  side  extends  from  the  lateral  portion  of  the 
uterus  to  the  pelvic  wall  (Fig.  527).  The  attachment  to  the  uterus  extends 
all  along  the  side  of  the  organ  from  the  cervix  to  the  fundus,  and  there  is  a 


594 


DISEASES   OF    THE   UTERUS 


correspondingly  wide  attachment  to  the  pelvic  wall.  This  gives  a  broad 
band  of  tissue  (hence  the  name  ''broad"  ligament)  extending  from  the  lateral 
margins  of  the  uterus  to  the  pelvic  wall  and  holding  the  uterus  in  its  ap- 
pointed position  in  the  center  of  the  pelvic  cavity  (Figs.  4,  527).  Each  broad 
ligament  is  composed  of  two  layers  of  peritoneum  (Fig.  512),  and  between 
them  are  a  number  of  important  structures.  This  disposition  of  the  peritoneum 
and  consequent  formation  of  the  broad  ligaments,  is  represented  very  well 
by  a  thin  cloth  laid  over  the  pelvis  and  then  tucked  down  snugly  around  the 
pelvic  organs.  The  peritoneum  covering  the  anterior  surface  of  the  uterus, 
when  continued  laterally  forms  the  anterior  layer  of  the  broad  ligament,  and 
that  covering  the  posterior  surface  of  the  uterus,  continued  laterally,  forms 
the  posterior  layer  of  the  broad  ligament.    Between  these  two  layers  of  peri- 


Fig.  527.     The    Ligaments    of    the    Uterus.      (Hodge — Diseases    Peculiar   to    Women.) 

toneum  is  a  considerable  amount  of  connective  tissue  and  also  the  following 
important  structures: 

a.  Fallopian  tube   (Figs.  3,  4,  5). 

b.  Ovary  (Fig.  4).  This  is  not  really  situated  in  the  broad  ligament  but 
rather  on  the  posterior  surface  of  the  ligament.  There  is,  however,  a  break 
in  the  peritoneum  at  this  point  through  which  the  hilum  of  the  ovary  is  in 
direct  continuation  with  the  connective  tissue  and  vessels  of  the  broad  liga- 
ment (Fig.  718). 

c.  Parovarium  (Figs.  505,  732,  733). 

d.  Ovarian  vessels  (Fig.  524). 

e.  Round  ligament  (Figs.  5,  527). 

f.  Uterine  vessels  (Figs.  523,  524). 

g.  Ureter.  The  ureter,  in  its  course  to  the  bladder,  lies  in  the  lower  part 
of  the  broad  ligament,  near  the  cervix  and  just  under  the  uterine  artery 
(Figs.  523,  524,  525). 


PATHOLOGIC    CHANGES  595 

PATHOLOGIC  CHANGES 

By  the  term  ''pathologic  changes"  as  here  used,  the  author  does  not 
refer  to  diseases,  but  only  to  individual  structural  changes,  as  encountered 
in  various  combinations  in  the  inflammatory  and  nutritive  diseases  of  the 
uterus. 

An  entirely  satisfactory  classification  of  the  inflammatory  and  nutritive 
diseases  of  the  uterus  is  not  possible  along  the  simple  lines  which  suf&ee  in 
some  other  localities. 

A  SYMPTOMATIC  classification  is  found  wanting  because  cases  giving  the  same 
symptoms  may  present  very  different  etiologic  factors  and  pathologic  condi- 
tions— in  fact,  the  same  case  may  show  several  distinct  pathologic  changes 
in  combination.  On  the  other  hand,  a  classificatioii  strictly  according  to 
ETIOLOGY  or  PATHOLOGY  alonc,  is  not  satisfactory,  for  the  same  etiologic  factors 
may  give  rise  to  various  pathologic  changes,  and,  again,  pathologic  changes 
essentially  the  same,  may  give  rise  to  various  clinical  pictures.  So  true  is  this, 
that  in  many  cases  it  is  impossible,  from  the  symptoms  and  usual  examina- 
tion signs,,  to  determine  certainly  the  etiology  of  the  trouble  or  the  exact 
pathologic  changes  present. 

The  best  way  to  present  this  subject  is  to  give  first  the  essential  patho- 
logic changes  that  take  place  in  the  uterus  as  the  result  of  inflammatory  and 
nutritive  disturbances,  and  then  to  take  up  the  separate  diseases,  classified 
largely  according  to  symptoms  but  bearing  in  their  titles  such  etiologic  and 
pathologic  distinctions  as  are  usually  easily  determined. 

The  nutritive  changes  found  in  the  uterus  are  due  largely  to  modifica- 
tions in  the  quantity  or  quality  of  the  blood  supplied  to  the  tissues,  though 
the  innervation  and  the  lymph  flow  probably  exercise  some  influence.  The 
quantity  and  quality  of  blood  supplied  to  the  uterus  may  be  modified  by  many 
conditions,  for  example,  general  diseases  causing  pronounced  anemia,  acute 
diseases  causing  toxins  and  other  abnormalities  in  the  blood,  heart  disease 
causing  venous  congestion  of  the  uterus,  acute  pelvic  inflammation  causing 
arterial  congestion  of  the  uterus,  tumors  and  malposition  causing  venous  con- 
gestion, etc.  How  all  these  various  conditions  might  indirectly  influence  the 
blood  supply  of  the  uterus  by  directly  affecting  ovarian  function,  will  be  dis- 
cussed in  Chapter  xv. 

Under  nutritive  changes  may  be  classed  the  following: 
Hyperemia  (arterial  and  venous). 
Serous  infiltration. 
Hemorrhagic  infiltration. 
Disintegration  and  liquefaction. 
Hyperplasia. 
Hypertrophy. 


596  DISEASES   OF    THE   UTERUS 

Atrophy. 

Obstruction  of  glands,  with  cystic  dilatation. 

Hyaline  degeneration. 

The  inflammatory  changes  are  due  to  severe  local  irritation.  The  local 
irritation  may  be  due  to  chemical  substances  (as  in  cauterization  of  the  endo- 
metrium with  penetrating  chemicals)  or  to  heat  (as  in  cauterization  by  steam) 
or  to  invading  cells  (as  in  cancer)  or  to  bacteria  and  their  products  (as  in 
the  various  infections).  Bacteria  and  their  products  constitute  by  far  the 
most  frequent  cause.  In  inflammation,  the  nutrition  of  the  tissues  is  more  or 
less  disturbed  and  consequently  there  may  occur  any  of  the  various  nutritive 
changes  already  mentioned,  in  addition  to  the  changes  distinctive  of  inflam- 
mation. 

The  inflammatory  changes  are  as  follows: 

Eound  cell  infiltration  (leukocyte  infiltration  and  lymphocyte  in- 
filtration.) 
Connective  tissue  formation. 
Thrombosis. 
Necrosis. 

Abscess  formation. 
J  Sloughing. 

Space  is  too  limited  to  accommodate  the  details  of  these  various  patho- 
logic changes.  Each  change  mentioned,  however,  has  definite  characteristics 
and  significance,  which  will  be  found  elucidated  in  Avorks  on  Pathology. 

CLASSIFICATION  OF  DISEASES 

In  the  inflammatory  and  nutritive  diseases  of  the  uterus,  there  are  all 
gradations  in  pathologic  conditions,  from  a  slight  nutritive  disturbance  in  a 
uterus  otherwise  normal,  to  the  terminal  stage — cirrhosis — which  represents 
complete  destruction  of  the  uterus  as  a  functionating  organ.  The  process  is 
progressive  and  depends  on  two  factors — irritation  and  poor  nutrition,  usu- 
ally represented  respectively  by  bacteria  and  inadequate  blood  supply.  One 
or  the  other  of  these  factors  is  always  present,  and  in  many  cases  both  are 
present,  the  character  of  the  disease  depending  on  the  predominating  factor. 

Though  no  entirely  satisfactory  classification  of  the  inflammatory  and 
nutritive  diseases  of  the  uterus  has  yet  been  devised,  still  there  are  classifica- 
tions that  do  very  well  for  practical  purposes.  The  following  classification 
is  the  one  found  most  convenient.  It  is  practical,  in  that  the  various 
named  conditions  are  as  a  rule  distinguishable  at  the  bedside,  and  the  names 
are  sufficiently  distinct  and  accurate  to  indicate  in  a  general  way  the  pathol- 
ogy of  the  conditions  named. 


LOCALIZATION    OF   DISEASES  597 

In  tlie  cervix  uteri  there  occur  the  following  inflammatory  and  nutritive 
diseases : 

Erosion  of  cervix.  _^y 

Ulcer  of  cervix. 

Acute  endocervicitis. 

Chronic  endocervicitis. 

Laceration  of  cervix. 

Idiopathic  hypertrophy  of  cervix. 

Polypi  of  cervix. 

In  the  corpus  uteri  there  occur  the  following  inflammatory  and  nutritive 
diseases : 

Endometrium  hyperplasia. 

Acute  infected  endometritis  and  metritis. 

Acute  simple  endometritis. 

Chronic  infected  endometritis. 

Subinvolution  of  uterus. 

Hyperinvolution  of  uterus. 

Sclerosis  of  uterus. 

Tuberculosis  of  uterus. 

Syphilis  of  uterus. 

Echinococcus  disease  of  uterus. 

LOCALIZATION  OF  DISEASES 

The  diseases  under  consideration  are  situated  in  various  parts  of  the 
uterus.  Some  of  them,  particularly  gonorrheal  and  septic  infection,  show  a 
marked  tendency  to  affect  all  portions  of  the  genital  tract — spreading  from 
the  cervix  to  the  endometrium  and  from  there  to  the  Fallopian  tubes  and  to 
the  peritoneal  cavity,  and  also  through  the  wall  of  the  uterus  to  the  peri- 
uterine connective  tissue  and  to  the  peritoneum.  In  tubercular  infection  the 
progress  is  generally  downward,  the  infection  spreading  from  the  Fallopian 
tubes  to  the  endometrium.  Other  processes  affect  the  whole  uterus  simul- 
taneously, though  in  varying  degree,  for  example,  subinvolution  following 
labor  or  abortion.  Still  other  inflammatory  or  nutritive  processes  are  local- 
ized to  one  part  of  the  organ,  for  example,  erosion  (cervix),  simple  endo- 
metritis (endometrium). 

The  inflammatory  and  nutritive  diseases  are  localized  principally  as  fol- 
lows : 

a.  Vaginal  Surface  of  Cervix.  This  is  the  seat  of  erosions  and  of  ulcers 
of  various  kinds. 

b.  Cervical  Mucosa  and  Adjacent  Tissues.  Here  are  found  acute  endo- 
cervicitis (septic  and  gonorrheal),  chronic  endocervicitis  (septic,  gonorrheal 
and  glandular)  and  cervical  polypi.    In  endocervicitis  the  process  is  not  con- 


598  DISEASES    OF    THE    UTERUS 

fined,  to  the  cervical  mucosa  but  invades  the  adjacent  tissues  to  a  greater 
or  less  extent,  hence  it  is  sometimes  called  cervical  metritis,  signifying  that 
the  cervix  as  a  -whole  is  involved.  But  the  process  starts  in  the  mucosa  and. 
the  principal  changes  are  found  there,  conseciuently  the  term  ''endocervicitis" 
seems  preferable. 

c.  Muscular  and  Connective  Tissue  of  the  Cervical  Wall.  Occasionally  an 
acute  inflammatory  process  is  prhicipally  localized  here  and  may  result  in  an 
abscess.  Usually,  however,  the  changes  in  these  tissues  are  either  secondary 
to  endocervicitis,  resulting  in  cellular  infiltration  and  connective  tissue  forma- 
tion with  subsequent  sclerosis,  or  the  changes  are  primarily  nutritive  in  char- 
acter, partaking  of  the  nature  of  hyperplasia.  The  first  condition  (secondary 
cellular  infiltration)  is  found  accompanying  cystic  disease  and  all  inflamma- 
tions of  the  cervix,  particularly  chronic  infected  endocervicitis.  The  second 
condition  (hyperplasia)  is  found  in  the  so-called  "idiopathic  hypertrophy" 
of  the  cer^dx. 

d.  Endometrium  and  Adjacent  Tissues.  IMost  of  the  inflammatory  and 
nutritive  diseases  of  the  body  of  the  uterus  start  in  the  endometrium.  On 
account  of  the  absence  of  a  submucous  connective  tissue  layer  in  the  uterus 
(the  mucosa  being  placed  directly  on  the  muscular  wall),  inflammatory  proc- 
esses starting  in  the  endometrium  soon  affect  the  underlying  muscular  tissue, 
the  depth  to  which  the  serous  and  cellular  infiltration  extends  depending  on 
the  severity  and  duration  of  the  disturbance. 

The  endometrium  is  the  seat  of  a  hyperplasia  of  acute  endometritis  (septic 
or  gonorrheal),  of  chronic  endometritis  (septic  or  gonorrheal),  of  tuberculosis, 
and  occasionally  of  syphilis. 

6.  Muscular  and  Connective  Tissue  of  the  Corpus  Uteri.  These  tissues,  as 
previously  explained,  are  affected  in  practically  all  cases  of  endometritis,  but 
only  secondarily  and  in  a  minor  way.  The  inflammatory  and  nutritive  af- 
fections situated  T)rincipally  in  these  tissues  are  acute  diffuse  metritis  {^yiih 
or  without  abscess  formation),  cirrhosis  of  uterus  and  subinvolution. 

f.  Peritoneal  Coat  of  Uterus.  Those  diseases  affecting  principally  the 
peritoneal  layer  of  the  uterine  wall  are  considered  under  affections  of  the 
pelvic  peritoneum,  in  Chapter  x.  They  are  peritonitis  and  tuberculosis  of  the 
peritoneum. 

EROSION  OF  CERVIX 

An  erosion  of  the  cervix  is  an  area  on  the  vaginal  surface  of  the  cervix 
which  is  found  covered  with  columnar  epithelium,  and  consequently  presents  a 
reddened  inflamed  appearance.  Some  confusion  has  resulted  from  the  applica- 
tion of  the  term  "ulceration  of  cervix"  to  this  condition.  There  is  no  ulcer 
and  no  granulating  surface,  for  the  whole  area  is  still  covered  with  epithelium. 


EROSION    OF    CERVIX 


599 


Etiology  and  Pathology 

The  erosion  is  caused  by  an  irritating  vaginal  or  uterine  discharge.  The 
discharge  may  originate  in  the  vagina  (e.g.,  gonorrheal  vaginitis)  or  in  the 
cervix  (endocervicitis)  or  in  the  body  of  the  uterus  (endometritis).  Any  con- 
dition that  gives  rise  to  an  irritating  discharge  may  cause  an  erosion  of  the 
cervix. 

The  reddened  appearance  seen  in  erosion  is  due  to  the  development  out- 
side of  the  external  os  of  a  surface-covering  that  resembles  the  cervical 
mucosa,  i.e.,  there  is  but  one  layer  of  cells  and  they  are  columnar.  This  thin 
epithelial  layer  permits  the  underlying  vascular  tissue  to  show  through,  and 
thus  gives  the  area  its  red  appearance. 

On  microscopic  examination  the  red  patch  is  found  to  be  covered  with  a 


/^ 


■St 


■.'■0^'--  'm' 


Fig.  528.  Section  through  an  Erosion  of  the  Cervix.  At  the  right  is  the  normal  squamous 
epithelium  covering  the  vaginal  portion  of  the  cervix.  At  the  left  is  the  Area  of  Erosion,  showing  the 
papillary  projections  covered  with  a  single  layer  columnar  epithelium.  The  cavities  below  the  surface 
are  gland  cavities  somewhat  dilated,  showing  a  tendency  to  cyst  formation.  (A.  Martin — Atlas  of 
Gynecology.) 


single  layer  of  columnar  epithelial  cells  (Figs.  528,  529).  As  this  epithelial 
layer  proliferates,  however,  it  shows  a  marked  tendency  to  become  much 
folded,  forming  deep  depressions  and  tall  papillae,  a  condition  known  as  a 
papillary  erosion.  Not  infrequently  the  tips  of  the  papillae  or  folds  become 
adherent,  forming  closed  cavities  or  follicles  between  them,  which  become 
filled  with  secretion  or  exudate.     This  is  called  a  foUiciilar  erosion. 

Just  why  this  columnar  epithelium  should  develop  on  a  surface  previously 
covered  with  squamous  epithelium,  is  not  positively  known.  It  is  generally 
thought  to  be  due  principally  to  the  proliferation  or  outgrowth  of  the  mucosa 
of  the  cervical  canal  beyond  the  external  os,  the  proliferation  being  caused 
by  one  of  the  various  forms  of  irritation  previously  mentioned. 


600 


DISEASES   OF    THE   UTERUS 


Symptoms  and  Diagnosis 

The  symptoms  due  to  the  erosion  are  usually  obscured  by  the  symptoms 
of  the  causative  lesion.  The  erosion  causes  some  increase  in  the  discharge. 
The  cervix  is  so  insensitive  that  but  little  if  any  pain  results.  On  examina- 
tion, a  muco-purulent  discharge  is  found.  When  the  cervix  is  exposed,  a  red- 
dened angry-looking  area  is  seen  about  the  external  os,  extending  outward 
irregularly  and  gradually  shading  into  the  normal  covering  (Figs.  414,  415). 
Though  the  lesion  is  superficial,  it  may  bleed  when  touched. 

The  lesions  which  may  be  confused  with  erosion  of  the  cervix  are  super- 
ficial abrasion,  ulcer  of  cervix,  and  eversion  of  mucous  membrane. 


Fig.   529.     An    Erosion    of   the    Cervix.      The   preserved    layer    of    squamous    epithelium    appears    in    the   left 
upper   oorner;    the  eroded   area,    in   the   right   upper   half. 


Superficial  abrasion  of  the  vaginal  portion  of  the  cervix  is  a  rather  rare 
condition  presenting  an  appearance  somewhat  like  an  erosion,  but  the  micro- 
scopic appearance  is  entirely  different.  Several  layers  of  the  epithelium  have 
been  rubbed  off  but  the  surface  is  still  covered  with  squamous  epithelium. 
An  abrasion  is  usually  due  to  mechanical  effect  (pressure  of  pessary  or  other 
foreign  body)  and  does  not  present  the  complicated  etiology  or  pathology  of 
erosion.  It  usually  occurs  at  the  point  where  the  pressure  comes  on  the  cervix 
(from  pessary  or  other  body)  and  not  especially  about  the  external  os,  as 
does  the  erosion.  '  Its  outline  is  not  so  well  marked  and  it  usually  disappears 
rapidly  after  the  cause  is  removed. 

An  ULCER  of  the  cervix  presents  a  clear-cut  border,  sometimes  raised  and 
indurated,  and  the  base  of  the  ulcer  is  formed  by  granulation  tissue.     The 


ULCER    OF    CERVIX  601 

different  forms  of  ulcer  simple,  chancroidal,  syphilitic,  tubercular,  malignant) 
present  also  special  characteristics,  which  will  be  given  later. 

In  EVERSiON  OF  MUCOUS  MEMBRANE  from  laceration,  the  fact  that  the  cervix 
has  been  lacerated  is  apparent,  and  close  examination  of  the  reddened  sur- 
face will  show  that  it  is  turned-out  endoeervical  mucous  membrane.  An  ero- 
sion of  the  cervix  may  coexist  with  eversion,  in  fact,  the  combination  is  very 
frequent,  the  erosion  being  due  to  the  irritating  discharge  caused  by  the 
laceration  and  eversion. 

Treatment 

1.  Eemove  the  cause.  If  due  to  the  irritation  of  a  pessary,  the  pessary 
must  be  removed  for  a  time.  If  due  to  an  irritating  discharge  from  the 
vagina  or  uterus,  the  primary  lesion  (causing  the  discharge)  must  receive 
appropriate  treatment. 

2.  Keep  the  vagina  clean  with  antiseptic  douches  taken  once  or  tAvice  or 
three  times  daily,  the  frequency  depending  on  the  amount  of  discharge. 

3.  Every  second  or  third  day  apply  some  antiseptic  astringent,  for  ex- 
ample, a  10%  solution  of  silver  nitrate  or  protargol  or  copper  sulphate,  and 
then  dust  in  an  antiseptic  astringent  powder  and  introduce  a  dry  tampon 
against  the  cervix.  The  tampon  is  to  be  removed  the  next  morning  and  the 
douches  continued  until  the  next  office  treatment. 

ULCER  OF  CERVIX 

An  ulcer  of  the  cervix  is  an  area  on  the  cervix  which  has  lost  its  epi- 
thelial covering  down  to  connective  tissue,  the  base  being  formed  by  granula- 
tion tissue  or  slough  as  is  well  shown  in  the  photomicrographs  illustrated  in 
Figs.  530  and  531. 

The  causes  of  an  ulcer  of  the  cervix  are  simple  irritation  (as  from  a  pes- 
sary or  a  very  irritating  discharge  or  from  rubbing  of  the  clothing  when  the 
uterus  is  prolapsed),  chancroidal  infection,  syphilis,  tuberculosis,  and  malig- 
nant disease. 

The  essential  pathology  is  stated  in  the  definition.  It  differs  from  an 
erosion  in  that  there  is  a  distinct  break  in  the  epithelial  covering  of  the  cervix. 

Symptoms  and  Diagnosis 

The  most  prominent  symptom  of  ulcer  of  the  cervix  is  vaginal  discharge, 
which  is  sometimes  streaked  with  blood.  When  the  cervix  is  exposed  with 
the  speculum  the  ulcer  on  its  surface  comes  into  view.  It  may  be  large  or 
small,  superficial  or  deep.    It  often  bleeds  when  touched. 

The  conditions  that  may  be  confounded  with  ulcer  of  the  cervix  are  ero- 
sion of  cervix  and  laceration  of  cervix  with  eversion  of  mucosa.    In  erosion  the 


602 


DISEASES    OF    THE    UTERUS 


lesion  is  very  superficial  and  usually  surrounds  the  external  os  and  the  whole 
surface  is  still  covered  with  epithelium.  The  cause  is  usually  apparent  and 
there  is  no  raised  clear-cut  border  nor  sunken  base.  In  laceration  of  cervix 
with  eversion  of  mucosa,  the  laceration  is  apparent,  and  by  clearing  all  secre- 
tion from  the  reddened  surface  and  examining  it  closely,  it  can  be  seen  that 
it  is  mucous  membrane  and  not  granulation  tissue. 

After  the  diagnosis  of  ulcer  is  established,  the  next  step  is  to  determine 
what  kind  of  an  ulcer  it  is.  A  rapidly  spreading  ulcer  with  undermined  or 
punched-out  edges,  following  suspicious  intercourse,  is  probably  chancroidal. 


Fig.  530.  An  Ulcer  of  the  CervLx.  Squamous 
■epithelium  is  seen  at  upper  and  lower  end  but  is 
absent   over  the  surface   of  the   ulcer   in  the   middle. 


Fig.  531.  Upper  edge  of  section  shown  in  Fig. 
530,  under  higher  magnification.  The  layer  of  squa- 
mous epithelium  above  terminates  abruptly  at  the 
edge   of  the   ulcer. 


A  chronic  ulcer  resisting  treatment  is  either  syphilitic,  tubercular  or  malig- 
nant. If  syphilitic,  there  will  be  other  evidences  of  syphilis  and  spirochetes 
may  be  recovered  from  its  surface.  It  must  be  remembered  that  not  so  rarely 
a  primary  chancre  may  be  located  on  the  cervix.  If  tubercular,  scrapings 
from  the  surface  or  sections  of  tissue  will  show  tubercle  bacilli.  A  malignant 
ulcer,  that  is,  an  ulcer  due  to  the  breaking  do^^Ti  of  malignant  infiltration, 
usually  presents  a  wide  area  of  infiltration  about  the  ulcerated  portion.  It 
shows  also  a  decided  tendency  to  bleed  and  the  bleeding  is  not  stopped  by 


ACUTE   ENDO  CERVICITIS  603 

the  repeated  application  of  10%  copper  sulphate  solution.  If  the  patient  is 
aged,  that  increases  the  probability  of  the  trouble  being  malignant.  Any 
chronic  ulcer  resisting  treatment  without  apparent  cause  (persistent  irrita- 
tion, syphilis  or  tuberculosis)  is  probably  malignant,  and  should  have  a 
piece  excised  for  microscopic  examination,  that  malignant  disease  may  be 
excluded  or  proved. 

Treatment 

The  treatment  depends,  of  course,  on  the  character  of  the  ulcer. 

In  simple  ulcer.  If  due  to  a  pessary,  remove  the  pessary  and  give  a  hot 
antiseptic  douche  two  or  three  times  daily,  dependmg  on  the  amount  of  dis- 
charge. Also  every  other  day  or  every  third  day,  introduce  the  speculum, 
expose  the  ulcer,  make  an  application  of  copper  sulphate  (10%)  or  some  other 
astringent,  and  then  dust  on  an  antiseptic  astringent  powder  and  introduce 
a  tampon  to  hold  the  powder  in  place  against  the  cervix.  The  tampon  is  to 
be  removed  the  next  morning  and  the  douches  continued  until  the  next  office 
treatment. 

A  chancroidal  ulcer  which  spreads  in  spite  of  the  measures  mentioned 
under  simple  ulcer,  should  be  cauterized  deeply  with  carbolic  acid  and  then 
treated  the  same  as  a  simple  ulcer. 

In  syphilitic  ulcer  the  patient  should  receive  constitutional  treatment. 
The  local  treatment  is  about  the  same  as  for  simple  ulcer. 

A  tubercular  ulcer  without  decided  tuberculosis  elsewhere,  should  be  ex- 
cised if  its  situation  will  admit.  If  it  can  not  be.  excised  it  should  be  thor- 
oughly curetted  and  cauterized  deeply  with  carbolic  acid  or  nitric  acid  or 
lactic  acid  or  the  thermocautery.  After  cauterization,  the  treatment  is  the 
same  as  for  simple  ulcer,  except  that  the  use  of  iodoform  is  especially  indi- 
cated. If  the  ulcer  extends  some  distance  up  the  cervical  canal  or  is  asso- 
ciated with  tuberculosis  of  the  endometrium  or  Fallopian  tubes,  hysterectomy, 
vaginal  or  abdominal,  is  indicated,  provided,  of  course,  that  there  is  no  other 
lesion  contraindicating  such  a  course.  At  the  same  time,  internal  antituber- 
cular  remedies  are  indicated. 

If  the  ulcer  is  malignant  (carcinoma  or  sarcoma)  the  uterus  should  be 
removed  at  once. 

If  the  character  of  the  ulcer  is  doubtful,  and  remains  so  after  a  short 
course  of  treatment,  excise  a  piece  of  tissue  from  the  margin  of  the  ulcer  and 
submit  it  to  a  pathologist  for  microscopic  examination. 

ACUTE  ENDOCERVICITIS 

Acute  endocervicitis  is  acute  inflammation  of  the  lining  of  that  portion 
of  the  uterine  canal  lying  between  the  external  and  internal  os.  It  is  some- 
times called  "acute  cervical  endometritis"  and  ''cervical  metritis," 


604  DISEASES    OF    THE   UTERUS 

Etiology  and  Pathology 

Acute  endocervicitis  is  due  to  infection  with  the  gonococcus  or  with  ordi- 
nary pus  germs.  In  gonorrheal  vaginitis,  the  inflammation  frequently  ex- 
tends into  the  cervix  and  may  remain  in  check  there  for  some  time.  If  in  a 
case  of  gonorrheal  vaginitis  applications  are  made  within  a  healthy  cervix, 
gonorrheal  endocervicitis  is  likely  to  result.  Some  authorities  hold  that 
gonorrheal  endocervicitis  is  usually  the  primary  lesion  and  that  the  vagina  is 
infected  secondarily.  This  probably  occurs  in  some  cases  but  it  is  hardly  to 
be  considered  the  rule. 

Ordinary  septic  endocervicitis  may  follow  labor  or  abortion,  but  then  it 
is  usually  overshadowed  by  the  more  serious  inflammation  in  the  body  of  the 
uterus,  i.e.,  the  septic  endometritis. 

The  pathologic  changes  are  practically  the  same  whether  the  inflamma- 
tion be  ordinary  septic  or  gonorrheal,  except  that  the  former  is  usually  ac- 
companied by  mechanical  injuries  (cervical  lacerations).  The  changes  are 
hyperemia  and  swelling  of  the  mucosa,  serous  infiltration  and  round  cell  in- 
filtration (leukocyte  and  lymphocyte),  with  increased  secretion. 

Sjnnptoms  and  Diagnosis 

The  principal  symptom  of  acute  endocervicitis  is  increased  discharge  from 
the  cervix  with  irritation  resulting  therefrom  (Figs.  412,  413).  The  cervical 
secretion  is  tenacious  and  stringy  and  resembles  the  white  of  an  egg  except 
that  it  is  less  fluid  and  more  jelly-like.  The  normal  cervical  secretion  is  alka- 
line. There  is  usually  considerable  erosion  about  the  external  os,  from  the 
irritating  discharge.  There  is  also  hyperemia  of  the  cervix  and  bleeding"  on 
slight  manipulation.  The  patient  has  an  uneasy  sensation  of  weight  and  dis- 
comfort in  the  pelvis,  though  acute  endocervicitis  alone  rarely  causes  pain. 
If  there  is  much  pain  it  is  probably  due  to  some  other  trouble,  for  which 
search  should  be  made. 

Acute  endocervicitis  causes  but  little  trouble  in  diagnosis.  The  irritating 
discharge  from  the  external  os  shows  that  there  is  inflammation  above  that 
point.  The  short  duration  excludes  chronic  endocervicitis  and  malignant 
trouble.  The  absence  of  pain  and  of  tenderness  of  the  body  of  the  uterus  on 
bimanual  examination,  and  the  absence  of  other  symptoms  of  endometritis, 
shows  that  the  inflammation  is  not  in  the  body  of  the  uterus,  consequently 
it  must  be  the  cervix.  "When  the  cervical  mucosa  is  touched  with  the  sound 
or  applicator  it  may  bleed,  showing  that  there  is  hyperemia  and  inflammation, 
and  confirming  the  diagnosis  previously  reached  by  exclusion.  The  bleeding, 
however,  is  not  a  prominent  feature,  not  nearly  as  prominent  as  in  cancer 
and  other  forms  of  ulcer.  In  endocervicitis,  the  character  of  the  discharge, 
which  is  markedly  tenacious,  indicates  that  most  of  it  comes  from  the  cervi- 
cal glands.     Whether  or  not  it  is  gonorrheal  may  be  determined  by  looking 


ACUTE   ENDOCERVieiTIS  605 

lor  evidences  of  gonorrhea  elsewhere  (vagina,  urethra,  vulvo-vaginal  glands) 
and  by  examining  the  discharge  for  gonocoeci. 

Treatment 

The  objects  of  treatment  in  a  case  of  acute  endocervicitis  are  three — (1) 
to  prevent  the  inflammation  from  spreading  to  the  mucous  membrane  of  the 
body  of  the  uterus,  (2)  to  prevent  the  inflammation  from  extending  deeply 
into  the  glandular  structure  of  the  cervix  where  it  will  become  chronic  and 
(3)  to  stop  the  irritating  discharge  and  the  consequent  discomfort.  In  all 
applications  and  other  manipulations  in  acute  endocervicitis,  if  the  body  of 
the  uterus  is  free  from  inflammation,  it  is  very  important  not  to  disturb  the 
internal  os.    The  plan  of  treatment  is  as  follows : 

1.  Apply  protargol  or  silver  nitrate  (4%  to  10%)  to  the  interior  of  the 
-cervix  every  second  or  third  day.  If  the  patient  has  gonorrheal  vaginitis, 
the  endocervical  application  is,  of  course,  made  at  the  same  time  that  the 
vagina  is  treated.  A  thin  strip  of  gauze  saturated  with  the  desired  liquid 
is  placed  in  the  cervix  and  held  in  place  for  twenty-four  hours  by  a  glycerine 
tampon.  The  tenacious  cervical  mucus,  which  prevents  the  medicine  from 
■coming  in  direct  contact  with  the  mucosa,  should  first  be  removed  with  the 
forceps  or  cotton- wrapped  applicator  or  small  euret.  A  weak  solution  of 
liquor  potassae  helps  in  clearing  out  this  mucus.  After  the  endocervical 
application,  a  tampon  soaked  in  boro-glyceride  or  in  ichthyol-glycerine  (10%) 
should  be  placed  against  the  cervix.  If  a  strong  astringent  application  is  de- 
sired, tannic-acid-giycerine  (10%)  may  be  used  on  the  tampon. 

2.  If  the  external  os  is  not  open  sufficiently  to  give  good  drainage,  it 
should  be  opened  by  dilatation  or  incision.  If  the  whole  cervix  is  congested 
and  swollen,  multiple  punctures  with  the  point  of  a  bistoury,  deep  enough  to 
give  free  bleeding,  is  beneficial. 

3.  Give  a  hot  antiseptic  vaginal  douche  (e.g.,  bichloride  douche)  every 
six  to  twelve  hours.  If  there  is  no  coincident  inflammation  of  the  vagina,  an 
astringent  douche  solution  may  be  used,  such  as  the  alum  and  zinc  sulphate 
■douche. 

4.  The  patient  should  do  but  little  walking  and  should  keep  rather  quiet, 
though  it  is  not  necessary  to  go  to  bed. 

Other  applications  which  have  been  found  beneficial  are  formol,  25%, 
tincture  of  iodine,  iodo-phenol,  carbolic  acid,  bichloride  solution  (1-500), 
ichthyol  (pure),  ichthyol  (25%)  in  glycerine  or  lanolin,  iodoform  in  ether 
(saturated  solution),  iodoform  and  tannic  acid  half  and  half.  Some  cases 
yield  better  to  one  application  and  some  to  another.  Skene  usually  used  a  mix- 
ture of  tincture  of  iodine  two  parts  and  carbolic  acid  one  part.  These  strong 
applications  should  not  be  made  oftener  than  every  five  to  seven  days.  The 
application  may  be  made  with  a  cotton-wrapped  applicator  dipped  into  the 


606  DISEASES   OF    THE   UTERUS 

solution  or  with  the  pipette,  by  which  a  small  amount  of  the  desired  solution 
is  placed  within  the  cervical  canal. 

Acute  endocervicitis  occurring  in  conjunction  with  acute  endometritis 
is  overshadowed  by  the  latter  and  requires  little  or  no  separate  treatment. 

CHRONIC  ENDOCERVICITIS 

Chronic  endocervicitis  is  chronic  inflammation  of  the  cervical  mucosa  and 
of  the  tissues  adjacent  thereto.  It  is  known  also  as  "cervical  catarrh," 
''glandular  endocervicitis,"  ''cystic  disease,"  "cystic  degeneration,"  "glan- 
dular degeneration, ' '  and  ' '  inflammatory  hypertrophy. ' ' 

Etiology  and  Pathology 

Chronic  gonorrheal  endocervicitis  and  chronic  septic  endocervicitis  usu- 
ally follow  acute  inflammation  of  like  character,  though  in  some  cases  the 
acute  symptoms  are  so  slight  as  ta  escape  notice. 

Laceration  of  the  cervix  is  a  fruitful  source  of  chronic  endocervicitis, 
often  without  the  intervention  of  acute  inflammation  in  any  form.  The  cervi- 
cal glands  and  lymph  spaces  are  torn  open  and  the  resulting  scar-tissue  ob- 
structs the  gland  ducts,  thus  leading  to  cystic  degeneration.  Laceration  also 
causes  eversion  of  the  mucosa  so  that  it  is  exposed  to  friction  against  the 
vaginal  wall,  with  consequent  chronic  inflammation.  Anything  that  causes 
uterine  congestion  tends  to  keep  up  the  endocervicitis. 

The  infecting  germs  penetrate  into  the  mucosa  of  the  cervix,  affecting 
the  glands  and  the  interglandular  tissue  and  causing  round  cell  infiltration. 
There  is  increased  secretion  from  the  cervix  and  the  discharge  is  irritating, 
causing  erosion  of  the  cervix  and  also  causing  vaginal  and  urethral  irritation. 
The  cervix  is  enlarged  and  chronically  congested,  and  eversion  of  the  mucosa 
takes  place.  If  there  has  been  laceration  with  eversion  of  mucosa,  the  chronic 
inflammation  still  further  everts  it.  When  there  has  been  no  cervical  lacera- 
tion, the  mucosa  may  still  become  everted,  thus  enlarging  the  external  os  and 
giving  the  appearance  of  laceration.  This  swelling  and  eversion  from  chronic 
inflammation  without  laceration,  may  take  place  in  the  virgin,  and  in  some 
cases  has  given  rise  to  an  erroneous  diagnosis  of  previous  pregnancy. 

In  chronic  endocervicitis  the  mucous  membrane  may  become  thickened 
irregularly,  from  the  hyperplasia  and  round  cell  infiltration,  and  thus  form 
papillary  growths.  If  this  process  goes  on,  it  may  form  polypi  ("mucous 
polypi,"  "cervical  polypi").  If  the  external  os  is  so  small  that  there  is  not 
good  drainage,  the  secretion  will  accumulate  in  the  cervical  canal  and  cause 
dilatation  above  the  external  os.  This  retention  of  irritating  material  may 
cause  ulceration  within  the  cervix. 

The  gland  ducts  become  obstructed,  causing  the  glands  to  be  distended 
into  small  retention  cysts.     These  distended  glands  are  felt  as  hard  nodules 


CHRONIC    ENDOCERVICITIS  607 

in  the  cervix  and  may  give  rise  to  an  erroneous  diagnosis  of  cancer,  especially 
when  associated  with  severe  laceration.  The  cervix  may  be  honeycombed 
with  these  small  cysts  (Figs.  539,  540),  producing  a  condition  designated  as 
''cystic  degeneration"  of  the  cervix.  Sometimes  one  or  more  of  the  cysts 
will  contain  pus  and  will  then  appear  as  a  yellow  spot  on  the  cervix.  Occa- 
sionally one  of  the  cysts  or  a  group  of  them  project  into  the  canal  and  finally 
become  pediculated,  forming  cervical  polypi.  Owing  to  the  chronic  inflam- 
mation, there  is  lymphocyte  infiltration  and  connective  tissue  proliferation, 
producing  enlargement  of  the  cervix- — called  by  Emmet  ''areolar  hyper- 
plasia." Later  the  contraction  of  this  inflammatory  tissue  causes  more  or 
less  disintegration  of  the  other  tissue  elements  and  finally  the  cervix  passes 
into  a  condition  of  cirrhosis  or  sclerosis,  corresponding  to  the  same  process  in 
the  body  of  the  uterus,  which  is  known  as  sclerosis  or  interstitial  metritis. 

The  long-continued  irritation  of  chronic  endocervicitis  and  cystic  dis- 
ease is  probably  an  important  factor  in  the  causation  of  cancer  of  the  cervix. 

Symptoms  and  Diagnosis 

The  symptoms  of  chronic  endocervicitis  are  chronic  vaginal  discharge 
and  erosion  of  cervix.  Associated  with  these,  but  due  principally  to  accom- 
panying lesions  (chronic  endometritis,  laceration  of  pelvic  floor,  pelvic  in- 
flammation), are  a  sense  of  weight  and  dragging  in  the  pelvis,  backache,  and 
pain  over  the  sacrum  (supposed  to  be  the  seat  of  reflex  pain  from  the  cervix.) 

Chronic  endocervicitis  must  be  distinguished  from  chronic  endometritis, 
laceration  of  cervix  and  cancer  of  cervix.. 

In  chronic  endometritis  there  is  usually  a  history  of  pain  in  the  lower  abdo- 
men and  some  menstrual  disturbance,  and  often  a  history  of  salpingitis.  Ex- 
amination shows  the  uterus  somewhat  enlarged  and  tender.  A  complicating 
salpingitis  is  evidence  that  the  inflammation  has  involved  the  body  of  the 
uterus  as  well  as  the  cervix. 

In  CERVICAL  LACERATION,  the  cervix  loses  its  pyramidal  shape  and  the  edges 
are  turned  outward  and  the  mucous  membrane  is  everted  or  replaced  by  scar- 
tissue.  The  cervix  is  broader  and  larger  than  normal  and  may  show  two  dis- 
tinct lips.  The  extent  of  the  tear  can  usually  be  better  determined  by  the 
sense  of  touch  than  by  sight,  but  the  extent  of  the  eversion  of  the  mucosa  is 
better  seen  than  felt.  The  two  conditions,  chronic  endocervicitis  and  cervi- 
cal laceration,  are  often  associated. 

In  BEGINNING  CANCER  of  the  ccrvix,  there  is  usually  an  area  of  induration. 
Also,  there  is  a  marked  tendency  to  bleed  on  manipulation  and  this  tendency 
to  bleed  is  not  removed  by  10%  copper  sulphate  applications.  Later,  the  dis- 
charge becomes  offensive  and  sanguino-purulent  and  contains  small  particles 
(crumbly  discharge),  but  the  diagnosis  should  be  made  before  these  marked 
evidences  develop,  as  it  may  be  too  late  then  to  effect  a  cure.  In  any  case  in 
which  there  is  a  suspicion  of  cancer,  a  small  piece  of  the  tissue  should  be  ex- 
cised for  microscopic  examination  (see  page  123). 


608  DISEASES    OF    THE    UTERUS 

Treatment 

In  chronic  inflammation  of  tlie  cervix,  attention  to  tlie  patient's  general 
health,  is  important.  Marked  anemia  and  lowered  vitality  from  any  canse, 
may  predispose  to  chronic  endocervicitis  or  canse  it  to  persist.  Consequently, 
if  such  conditions  are  present,  appropriate  treatment  for  the  same  should  be 
given.  Iron,  quinine  and  arsenic  are  often  indicated.  The  uric  acid  diathesis, 
or  lithemia,  is  prone  to  cause  persistence  of  chronic  cervical  inflammation. 
Diseases  causing  chronic  pelvic  congestion  are  especially  effective  in  the  same 
direction,  hence  measures  directed  toward  the  relief  of  pelvic  congestion  must 
be  employed.  In  all  eases  of  endocervicitis  the  most  important  step  in  treat- 
ment is  to  remove  the  cause  of  the  disease  when  that  is  possible.  Endometritis 
or  malposition  of  the  uterus  should  be  corrected  if  present,  and  the  patient 
should  be  put  on  a  regular  tonic  regime. 

Locally  the  steps  in  treatment  recommended  for  acute  endocervicitis  are 
indicated,  and  also  the  following  additional  measures : 

1.  If  there  are  cysts,  puncture  and  evacuate  them  and  touch  the  cavities 
with  some  antiseptic  astringent.  Cysts  projecting  into  the  canal  may  some- 
times be  located  -n-ith  a  probe  or  tenaculum.  They  should  be  treated  the  same 
as  those  on  the  external  surface.  If  necessary  for  the  proper  treatment  the 
canal  may  be  dilated.  If  the  external  os  is  too  small  to  permit  of  good  drain- 
age or  satisfactory  local  treatment,  it  should  be  opened  by  dilatation  or  in- 
cision. The  contracted  cervical  outlet,  or  ''pinhole  os, "  is  rather  freqquent 
in  nullipara  and  causes  retention  of  the  secretion  and  increased  irritation. 
In  such  a  case  if  the  os  does  not  yield  readily  to  dilatation  it  may  be  incised. 

It  is  sometimes  a  good  plan  to  curet  the  entire  cervical  canal  lightly  and 
then  apply  the  desired  medicine.  Strong  curettage,  however,  or  the  applica- 
tion of  a  strong  cauterant,  such  as  nitric  acid,  is  liable  to  cause  cicatricial 
stenosis,  which  later  requires  treatment  by  dilatation  or  incision. 

2.  If  there  is  considerable  laceration  of  the  cervix,  repair  it  as  described 
later.  This  is  particularly  important  if  there  is  hypertrophy  or  cystic 
disease.  In  the  denudation  for  reiDair,  a  large  part  of  the  cystic  portion  may 
be  excised. 

3.  If  the  cystic  disease  is  still  more  marked,  the  cervix  may  be  partially 
amputated  by  Schroeder's  method  (Fig.  542).  This  operation  removes  the 
cystic  and  infiltrated  tissue  on  the  inner  side  of  the  cervical  lips  and  at  the 
same  time  preserves  the  outer  part  of  the  cervix,  which  is  comparatively  nor- 
mal. • 

LACERATION  OF  CERVIX  UTERI 

Etiology 

The  usual  cause  of  laceration  of  the  cervix  is  the  passage  of  the  head 
and  shoulders   of  the   child  in  labor.     The  cervix  will  stretch  wonderfully 


LACERATION    OF    CERVIX   UTERI  609 

when  softened  by  pregnancy  and  slowly  dilated  by  the  bag  of  waters,  but 
still  there  is  nearly  always  some  laceration. 

In  operations  on  the  non-pregnant  uterus,  such  as  curetment,  the  cervix 
is  occasionally  torn  in  the  preliminary  dilatation. 

A  congenital  split  resembling  a  lateral  laceration  of  the  cervix  has,  in  a 
few  instances,  been  observed  in  the  newborn  infant.  This  congenital  notch 
is  of  little  importance  except  that  when  seen  in  the  adult  it  may  lead  to  an 
erroneous  diagnosis  of  previous  pregnancy.  A  distinct  laceration  of  the  cer- 
vix is  one  of  the  strongest  proofs  of  previous  pregnancy  and  the  fact  that  a 
congenital  notch  somewhat  resembling  a  laceration  may  occur,  is  of  medico- 
legal importance. 

Pathology 

The  tear  of  the  cervix  in  labor  usually  affects  both  sides  causing  a 
bilateral  laceration,  with  one  side  torn  deeper  than  the  other  (Figs.  317,  416). 
Occasionally  only  one  side  is  torn  giving  a  unilateral  ulceration  (Figs.  315, 
416).  Sometimes  the  cervix  is  torn  in  several  directions  giving  a  stellate 
laceration  (Fig.  415).  Still  another  variety  is  the  internal  laceration,  a  tear 
not  extending  entirely  through  the  wall. 

Tears  of  the  cervix  are  of  all  grades  of  severity.  The  tear  may  be  very 
slight,  leaving  after  some  weeks,  only  a  small  notch  or  depression  (Fig.  313), 
or  it  may  be  very  deep,  even  extending  into  the  vaginal  and  pericervical  con- 
nective tissue  or  into  the  bladder.  In  the  deep  tears,  the  lips  may  fall  to- 
gether and  heal  fairly  well  so  that  only  a  small  notch  is  left.  On  the  other 
hand,  the  lips  may  fail  to  unite  in  which  case  a  deep  notch  may  be  left  (Figs. 
317,  416).  Occasionally  the  cervix  heals  in  such  a  way  as  to  leave  a  fistula 
from  the  cervical  canal  into  the  vagina  (cervico-vaginal  fistula).  In  the  case 
of  an  "internal  laceration"  the  cervix  may  appear  to  be  simply  dilated.  It 
is  open  or  patulous  and  the  examining  finger  may,  in  some  cases,  be  intro- 
duced as  far  as  the  internal  os.  In  this  form  of  tear,  the  conical  shape  of  the 
cervix  may  be  preserved  if  no  marked  inflammatory  change  has  taken  place. 
,  In  the  ordinary  bilateral  laceration  which  fails  to  unite  there  is  eversion 
of  the  cervical  mucosa.  The  mucous  membrane  lining  the  cervix  is  turned  out 
(Figs.  317,  416)  and  is  irritated  by  rubbing  against  the  vaginal  wall.  The 
irritation  of  the  cervical  mucosa  causes  increased  secretion  from  the  cervical 
glands  (Fig.  413).  Infection  leads  to  endocervicitis,  acute  and  chronic,  and 
this  inflammation  may  bring  about  destruction  of  the  mucous  membrane, 
which  is  then  replaced  by  scar-tissue.  The  rolling  out  of  the  lips  of  the  cervix 
may  progress  to  such  an  extent  that  the  notch  between  the  lips,  which  is  one 
of  the  signs  of  laceration,  is  obliterated — so  that  the  cervix  appears  as  a 
round  ball  (Fig.  532). 

Frequently  there  is  much  scar-tissue  covering  the  inner  portions  of  the 
cervical  flaps,  and  a  thick  wedge  of  sear-tissue  in  the  angle  of  the  tear  on 


610 


DISEASES    OF    THE    UTERUS 


each  side.  The  ducts  of  the  cervical  glands  become  obstructed  by  the  inflam- 
mation and  scar-tissue  contraction  and  small  cysts  are  thus  formed,  causing 
nodules  in  the  cervix  (Figs.  559,  560).  These  small  cysts  feel  like  shot  of 
various  sizes  in  the  cervix.  This  indurated  and  nodular  condition  may  lead 
to  an  erroneous  diagnosis  of  malignant  infiltration.  If  these  nodules  be  punc- 
tured and  then  pressed  upon,  a  thick  glairy  mucus  is  extruded,  leaving  a 
small  cavity.  In  some  cases,  the  cervix  is  riddled  with  these  cysts,  a  condi- 
tion known  as  cystic  degeneration  or  cystic  disease  of  the  cervix.  Subinvolu- 
tion of  the  uterus  is  a  secondary  result  of  laceration  of  the  cervix.  The  uterus 
remains  large  and  heavy  and  drags  on  its  supports.  Another  secondary  change 
is  hypertrophy  of  the  cervix  (Fig.  541).  O^^dng  to  the  chronic  inflammation 
and  chronic  congestion  and  the  cystic  disease,  the  cervix  gradually  enlarges 
and  becomes  hea^T  ai^^  sinks  do^^aiAvard  and  forward  in  the  pelvis. 


Fig.   532.     A    Lacerated    Cervix    in    which   there    is    so    much    aversion    that    the    Cervix    appears    as    a    round 

ball.      (Kelly — Operative    Gynecology.) 


In  some  cases,  however,  the  supposed  enlargement  and  elongation  is  only 
an  apparent  hjrpertrophy.  Even  in  the  cases  in  which  there  is  considerable 
hypertrophy  it  appears  to  be  more  than  it  really  is.  This  deceptive  condition 
is  due  to  eversion  of  the  lacerated  portion  of  the  cervix  and  descent  of  the 
uterus  and  reduplication  of  the  vaginal  wall.  That  this  is  the  true  condition 
may  be  shown  by  putting  the  patient  in  the  knee-chest  posture,  when  the 
uterus  will  gravitate  out  of  the  vagina  toward  the  abdominal  cavity  and  the 
point  of  attachment  of  the  vaginal  wall  to  the  cervix,  and  the  amount  of 
cervix  below  that,  may  be  seen.  Another  fact  brought  out  by  this  examina- 
tion in  the  knee-chest  posture  is  that  there  are  many  cases  of  laceration  of 
the  vaginal  vault  that  appear,  in  the  ordinary  examination,  to  be  laceration  of 
the  cervix  only.  Owing  to  the  sinking  of  the  uterus  and  reduplication  of  the 
vagina,  the  tear  appears  to  be  wholly  in  the  cervix.  AVhen  the  patient  is  put 
in  the  Sims  posture,  or  better  still  the  knee-chest  posture,  it  is  seen  that  the 
tear  extends  past  the  cervix  and  involves  the  vaginal  vault.    In  either  of  these- 


LACERATIOX    OF    CERVIX   UTERI  611 

conditions,   trachelorrhaphy    and   not   amputation   is   the    proper   treatment. 

Still  another  effect  of  a  deep  cervical  laceration  and  the  chronic  irrita- 
tion resulting  therefrom,  is  the  predisposition  to  the  development  of  cancer 
of  the  cervix.  This  danger  is  apparently  doubted  by  some  authorities  but  it 
is  a  real  danger  and  must  be  kept  in  mind. 

Laceration  of  the  cervix  as  seen  several  months  or  years  after  the  injury 
is  usually  accompanied  by  one  or  more  complications,  such  as  chronic  endo- 
metritis, retroversion,  or  loss  of  support  in  the  pelvic  floor. 

Symptoms  and  Diagnosis 

The  symptoms  depending  on  the  laceration  itself  and  on  the  resulting 
subinvolution  and  inflammation  are  numerous,  though  none  are  distinctly 
characteristic  of  cervical  laceration.  The  symptoms  are  nearly  all  due  to 
the  complications  rather  than  to  the  tear  itself. 

There  is  usually  a  vaginal  discharge,  or  leucorrhea,  due  both  to  the  cervi- 
cal injury  and  the  accompanying  endometritis.  When  there  is  a  preponder- 
ance of  cervical  secretion  in  the  discharge,  it  is  jelly-like  and  sticky  and  may 
be  pulled  out  into  long  threads,  and  it  is  hard  to  detach  from  the  cervical 
canal. 

Menstrual  Disturbances  usually  accompany  laceration  of  the  cervix,  but 
hey  are  due  largely  to  the  subinvolution  and  endometritis.  They  consist  of 
IDainful  menstruation  and  increased  menstrual  flow. 

Backache  and  dragging  pains  in  tlie  pelvis  are  usually  present  in  severe 
laceration  but  they,  like  the  menstrual  disturbances,  are  to  be  attributed 
largely  to  the  complications  such  as  laceration  of  pelvic  floor,  subinvolution, 
endometritis,  and  salpingitis. 

Dyspareunia  may  be  present  in  a  case  of  laceration  of  the  cervix  and  the 
probability  of  its  occurrence  is  increased  if  retroversion  is  present. 

Sterility  may  be  caused  by  a  cervical  tear,  the  increased  secretion  retard- 
ing the  progress  of  the  spermatozoa  or  the  cicatricial  contraction  causing 
stenosis.  Abortion  occasionally  results  from  an  old  ceiwical  injury  and  in 
cases  of  very  deep  tears,  the  abrasions  may  reoccur  habitually. 

Reflex  Symptoms  in  distant  organs  are  sometimes  excited  by  cervical  in- 
jury. A  familiar  example  is  the  increased  nausea  and  vomiting  of  pregnancy, 
often  seen  in  cases  of  severe  laceration  and  irritation  about  the  cervix.  In 
many  of  these  cases  the  cervix  is  tender,  and  pressure  upon  it  excites  stomach 
distress.  In  most  of  such  cases  an  application  of  silver  nitrate  solution  (4%) 
or  cocaine  solution  (10%)  to  the  cervix  will  give  much  temporary  relief,  in- 
dicating that  the  trouble  is  reflex  from  the  sensitive  cervix.  Among  the  reflex 
disturbances  sometimes  due  to  a  lacerated  cervix,  come  also  stomach  disturb- 
ances in  the  noii-pregnant,  persistent  neuralgia  and  headaches  (particularly 
headache  at  the  vertex)  and  a  general  nervous  irritability. 

The  reflex  influence  of  cervical  injuries  has  no  doubt  been  greatly  over- 


612  DISEASES    OF    THE    UTERUS 

estimated  by  some  writers,  and  affections  have  been  attributed  to  such  in- 
juries that  really  had  no  connection  with  them  or  were  at  most  only  aggra- 
vated by  them.  Laceration  of  the  cervix  is  frequently  accompanied  by  poor 
general  health  which  may  occasionally  be  due  to  the  local  and  reflex  disturb- 
ance from  the  cervix,  but  which  is  usually  due  to  some  complicating  disease. 

On  vaginal  examination  the  notch  in  the  cervix  may  be  distinctly  felt 
and  also  the  enlargement  and  the  cystic  condition  when  present.  If  there  is 
a  deep  tear,  the  anterior  and  posterior  lips  may  be  made  out.  When  the 
cervix  is  exposed  to  view  through  a  speculum  the  amount  of  eversion  of  the 
mucous  membrane  may  be  seen  and  also  any  area  of  erosion  caused  by  the 
irritating  discharge.  The  bivalve  speculum  may  distort  the  cervix  and  make 
it  appear  somewhat  more  widened  and  changed  in  shape  than  it  really  is. 
This  slight  distortion,  v\'hich,  however,  is  not  of  much  importance  ordinarily, 
may  be  avoided  by  using  the  Sims  posture  and  the  Sims  speculum. 

In  some  cases  the  flaps  have  rolled  outward  so  far  that  neither  notch 
nor  distinct  flaps  can  be  seen.  The  cervix  appears  simply  as  a  round  ball  (Fig. 
532)  instead  of  showing  two  distinct  lips.  By  catching  each  side  of  such  a. 
cervix  with  a  tenaculum  forceps,  near  the  point  that  was  formerly  the  ex- 
ternal OS,  and  bringing  these  points  together  (Figs.  417,  418),  it  may  be  seen 
that  the  cervix  has  been  torn  into  two  lips,  and  also  some  idea  may  be  gained 
of  the  depth  of  the  tear  and  the  appearance  of  the  cervix  when  repaired. 

Laceration  of  the  cervix  with  chronic  inflammation  must  be  distinguished 
from  the  following  conditions: 

a.  Erosion  of  the  cervix.  In  simple  erosion,  the  conical  shape  of  the 
cervix  is  preserved  (Fig.  415).  An  erosion  is  often  present  with  laceration 
as  a  result  of  the  irritating  discharge.  It  then  appears  around  the  everted 
mucosa  as  an  irregular  reddened  inflamed-looking  area. 

b.  Ulcer  of  cervix.  In  ulcer  without  laceration  the  conical  shape  of 
the  cervix  is  preserved.  Also,  an  ulcer  shows  destruction  of  the  epithelial 
covering  and  has  a  depressed  base  and  raised  margin. 

c.  Chronic  endocervicitis  without  laceration.  In  most  severe  cases  of 
chronic  endocervicitis,  there  has  been  laceration.  But  there  are  certain  eases 
of  endocervicitis  without  laceration,  in  which  the  mucosa  becomes  pushed 
out  and  everted  from  the  inflammatory  swelling,  and  the  condition  has  some- 
what the  appearance  of  laceration.  Such  an  appearance  has  led  to  an  er- 
roneous diagnosis  of  previous  pregnancy.  In  these  cases  the  cervix  as  a  whole 
preserves  its  conical  shape,  the  principal  disturbance  being  about  the  external 
OS,  which  may  appear  as  a  slit  instead  of  as  a  round  opening  and  may  be  sur- 
rounded by  swollen  everted  mucosa. 

d.  Cancer  of  cervix.  Usually  the  differential  diagnosis  is  easy.  In 
some  cases,  however,  when  the  cervix  is  deeply  torn  and  nodular  from  cysts, 
it  may  be  impossible  to  exclude  cancer  without  a  microscopic  examination  of 
an  excised  piece  from  the  suspicious  area. 

"With  a  lacerated  cervix  are  frequently  found  one  or  more  complications 


LACERATION    OF    CERVIX    UTERI  613 

■ — chronic  enclocervicitis  or  subinvolution  or  chronic  endometritis  or  retro- 
version or  prolapsus  uteri  or  chronic  salpingitis  or  chronic  pelvic  cellulitis 
or  chronic  oophoritis. 

All  the  lesions  present  in  a  case  should  be  determined  as  far  as  possible 
before  operative  treatment  is  undertaken,  for  some  of  them  may  require  treat- 
ment at  the  same  time. 

Treatment 

A  laceration  of  the  cervix  does  not  necessarily  cause  symptoms  or  re- 
quire treatment.  It  is  only  when  accompanied  by  certain  conditions  or  com- 
plications, mentioned  below,  that  it  requires  treatment.  The  treatment  for  a 
lacerated  cervix  is  repair. 

Trachelorrhaphy 

The  operation  for  repair  of  a  lacerated  cervix  is  kno^^ni  as  "trachelor- 
rhaphy." It  was  devised  by  Emmet  and,  together  with  Emmet's  operation 
for  repair  of  the  pelvic  floor,  stands  as  a  representative  of  the  careful  study 
given  to  pelvic  diseases  by  that  splendid  clinician. 

Indications.  A  lacerated  cervix  when  examined  after  several  months  or 
years,  may  iDresent  either  of  the  following  conditions : 

a.  A  small  notch  on  one  or  both  sides,  the  remainder  of  the  cervix  being 
normal  (Fig.  313).  Such  a  cervix  does  not  require  repair,  as  it  causes  no 
symptoms.. 

b.  A  deep  notch  on  one  or  both  sides,  the  lips  being  soft  and  of  normal 
size  and  without  irritation  (Fig.  315).  Such  a  cervix  does  not  ordinarily  cause 
any  disturbance.  Occasionally,  however,  the  scar-tissue  in  one  or  both  an- 
gles causes  local  tenderness  and  reflex  disturbance.  In  such  a  case  the  lacer- 
ation should  be  repaired. 

c.  The  cervix  presents  large  infiltrated  lips,  with  everted  mucous  mem- 
brane, cystic  formation,  an  irritating  discharge  and  spots  of  erosion.  (Figs. 
415,  316).  There  may  be  no  well-defined  flaps  or  lips,  simply  a  globular  ap- 
pearance of  the  swollen  cervix  (Fig.  532)  with  a  slit-like  os,  surrounded  by 
an  irregular  area  of  everted  mucosa,  granulation  spots  and  scar-tissue,  the 
whole  covered  more  or  less  with  a  mueo-purulent  discharge.  Such  a  cervix 
should  be  repaired,  not  only  on  account  of  the  troublesome  symptoms  re- 
sulting from  it,  but  also  because  it  predisposes  to   development  of  cancer. 

It  must  be  emphasized,  however,  that  the  simple  fact  that  a  cervix  has 
been  lacerated  is  not  an  indication  for  operation.  Operation  is  indicated 
only  when  there  are  troublesome  local  conditions  which  other  measures  fail 
to  relieve. 

Contraindications.  The  contraindications  to  this  operation  are  the  same 
as  the  contraindications  to  repair  of  the  pelvic  floor  (see  Chapter  v). 

Preparations.     The  preparations  for  the  operation  may  be  divided  into 


614  DISEASES    OF    THE    UTERUS 

preparation  of  patient,  preparation  of  instruments  and  dressings,  and  prepa- 
ration of  operator  and  assistants.  The  preparation  of  the  patient  is  both 
local  and  general.  When  the  cer^dx  presents  erosion  or  ulceration  or  cysts 
or  marked  infiltration  or  a  purulent  discharge,  it  should  be  subjected  to 
preparatory  treatment  as  follows : 

a.  Give  a  hot  antiseptic  douche  two  or  three  times  daily. 

b.  Puncture  the  cysts  and  touch  the  ca^dties  with  strong  silver  nitrate 
solution  or  other  antiseptic. 

c.  When  there  is  marked  congestion  and  infiltration,  bleed  the  cervix 
by  multiple  punctures  once  or  twice  weekly.  Draw  off  one  or  two  table- 
spoonfuls  of  blood  each  time  and  follow  the  bleeding  by  a  tampon  soaked 
in  boro-glyceride  or  ichthyol-glycerine.  Direct  the  patient  to  remove  the 
tampon. in  twelve  to  twenty-four  hours  and  then  continue  the  hot  douches  un- 
til the  next  office  treatment.  By  this  method  the  cervix,  in  the  course  of 
a  few  weeks,  may  be  reduced  considerably  in  size  and  put  in  much  better  condi- 
tion for  repair. 

d.  Treat  the  complications,  such  as  retroversion  and  endometritis. 

e.  Give  laxatives  and  tonics  as  necessary  to  put  the  patient  in  good  con- 
dition generally. 

f.  Before  operating  for  repair  of  the  cervix  the  patient  should  be  care- 
fully examined,  that  all  lesions  present  may  be  determined  and  taken  into 
consideration  in  the  treatment  and  prognosis.  It  may  be  found  that  the  lac- 
eration of  the  cervix  is  only  a  small  part  of  the  patient's  trouble  and  that 
her  principal  symptoms  are  due  to  malposition  of  the  uterus  or  to  loss  of 
support  in  the  pelvic  floor  or  to  endometritis  or  to  salpingitis  or  to  appendi- 
citis or  to  a  pelvic  tumor.  Many  bitter  disappointments  and  so-called  fail- 
ures have  followed  this  operation,  and  other  operations  also,  because  the  oper- 
ation was  expected  to  remove  symptoms  that  were  really  not  dependent  on 
the  lesion  attacked.  Such  a  mistake  may  be  avoided  by  examining  the  pa- 
tient carefully,  and  giving  to  each  lesion  present  its  due  importance  in  the 
production  of  the  complex  clinical  picture. 

Another  reason  for  ascertaining  carefully  all  lesions  present  is  that  some 
other  lesions  may  be  corrected  at  the  same  time  that  thh  cervix  is  repaired, 
for  example,  the  uterus  may  be  curetted  or  a  malposition  corrected  or  the 
pelvic  floor  repaired. 

In  preparing  for  the  operation  on  the  cervix  avoid  the  menstrual  flow 
for  ten  days  after  the  operation- — the  best  time  for  the  operation  being  four 
to  ten  days  after  menstruation. 

The  antiseptic  preparation  of  the  patient  is  the  same  as  for  repair  of 
pelvic  floor. 

The  preparation  of  instruments  and  dressings  is  the  same  as  for  Ab- 
dominal Section.  The  instruments  required  for  trachelorrhaphy  are  shown 
in  Fig.  533. 


OPERATION   FOR   LACERATION    OP    CERVIX   UTERI 


615 


The  preparation  of  the  operator  and  assistants  is  the  same  as  for  Ab- 
dominal Section  (see  Chapter  xvi). 

Steps  in  the  Operation.  After  the  patient  is  anesthetized  and  brought  to 
the  edge  of  the  table  (Fig.  559)  and  the  vagina  scrubbed  the  same  as  for 
curetment  (Fig.  560),  then  proceed  by  the  following  steps: 

1.  Make  a  careful  bimanual  examination,  under  anesthesia,  of  the  uterus 
and  tubes  and  ovaries.  "When  the  bimanual  examination  is  finished,  introduce 
the  self -retaining  speculum  and  expose  the  cervix  and  catch  it  with  a  tenaculum 
forceps. 

2.  If  chronic  endometritis  or  subinvolution  is  present,  curet  the  uterus. 
When  the  cervix  is  to  be  repaired  immediately  after  curetment,  no  gauze  need 
be  placed  in  the  uterus. 


Fig.  533.  Instruments  for  Repair  of  the  Cervix:  a,  Edebohl's  self-retaining  speculum,  to  which 
the  required  weight  is  attached  by  a  small  hook;  b,  right-angled  vaginal  retractor  (have  two);  c,  long 
tenaculum  forceps  (have  two);  d,  vaginal  dressing  forceps  for  sponging  (have  two);  e,  bistoury;  /,  long 
straight  scissors;  g,  long  cyrved  scissors;  h,  long  tissue  forceps;  i,  hemostat  forceps  (have  eight);  ;,  Sims 
needle-holder;  k,  number *2,  20-day  catgut  (have  six  tubes)  and  silkworm-gut  (have  eight  strands)  and 
strong  cervix  needles  (have  four).  These  needles  should  have  sharp  trocar-points,  so  as  to  easily 
penetrate  the   hard  tissue   of  the   cervix. 


3.  Outline,  by  incision  with  the  bistoury,  the  area  to  be  denuded,  leaving 
in  the  center  of  each  lip  a  strip  about  a  third  of  an  inch  wide,  to  form  the 
new  cervical  canal  (Figs.  534,  537).  The  strip  of  tissue  to  be  left  should  be 
wide  enough  so  that  no  stricture  will  result,  after  the  healing  and  involution. 
Watch  this  point  particularly,  as  some  stenosis,  requiring  dilatation,  sometimes 
follows  trachelorrhaphy.  It  is  a  good  plan  to  leave  the  strip  a  trifle  wider 
at  the  external  os  (Fig.  537). 

The  area  of  denudation  should  include  all  the  area  of  everted  mucous 


616 


DISEASES   OF    THE   UTEEUS 


Fig.   534.     Areas   for  Denudation   Outlined   by   incision   with  the  knife.      This   shows   also   the 
Method   of   Denuding  with   the   scissors.      (Hirst — Diseases   of    Women.) 


Fig.  535.  The  Area  of  Denudation  outlined  on 
a  Kough  Lacerated  Cervix.  The  angles  of  the 
tear  are  situated  near  a  and  b.  The  mucosa  to  be 
left  to  form  the  new  cervical  canal,  lies  between 
the  lines  d-d'  and  c-c',  (Thomas  and  Munde — Dis- 
eases of   Women.) 


Fig.  536.  Incision  through  the  Scar-tissue  at  the 
angles  of  the  laceration.  (Kelly — Operative  Gyne- 
cology.) 


OPERATION   FOR   LACERATION    OF    CERVIX   UTERI  617 

membrane  and  scar-tissue,  and  should  extend  slightly  outward  on  the  vaginal 
surface  of  the  cervix  so  as  to  give  a  wide  surface  of  denudation  for  approxi- 
mation. 

4.  Denude.  A  very  good  way  is  to  first  make  an  incision  deep  in  the  an- 
gle of  each  side  (Fig.  536).  This  should  extend  through  the  scar-tissue  into 
healthy  tissue.  Then  catch  the  lower  angle  of  the  strip  to  be  removed  from 
one  side  of  the  lower  lip  and,  while  holding  this  with  the  tissue  forceps,  clip 
it  loose  w4th  the  scissors,  straight  or  curved  as  preferred  (Fig.  534).  This 
process  of  cutting  is  continued  all  the  way  to  the  base  of  the  flap.  The  upper 
part  of  the  same  side  of  the  cervix  is  treated  the  same  way,  and  then  the  other 
side  of  the  cervix.  Beginning  below  diminishes  the.  inconvenience  from  the 
bleeding.  Special  care  should  be  taken  to  remove  all  scar-tissue  from  the 
angles.  Cysts  in  the  area  of  denudation  should  be  excised.  If  the  surfaces 
are  brought  together  with  cysts  in  them,  the  operation  is  liable  to  do  mure 
harm  than  good,  as  the  cysts  may  continue  to  develop  in  their  buried  situation 
and  produce  reflex  disturbances.  If  cystic  areas  can  not  be  readily  excised  so 
as  to  permit  good  approximation  for  trachelorrhaphy  the  areas  of  cystic 
degeneration  should  be  removed  by  Sehroeder's  partial  amputation,  explained 
later. 

For  denuding,  some  prefer  a  knife,  some  a  straight  scissors  and  some  a 
curved  scissors.  The  ''hawk-bill"  scissors  of  Skene  are  very  convenient  for 
biting  the  scar-tissue  out  of  the  angles  of  the  tear. 

5.  Introduce  the  sutures.  After  the  denudation  is  complete,  the  cervix 
is  cleansed  with  the  antiseptic  solution,  and  the  sutures  are  passed.  The  first 
suture  is  introduced  at  the  upper  angle  of  the  wound,  as  shown  in  Fig. 
537.  As  each  suture  is  passed  its  ends  are  caught  in  a  hemostatic  forceps 
find  held  out  of  the  way.  The  next  suture  is  passed  one-fourth  to  one-third 
of  an  inch  below  the  first,  and  so  on  cIoaahi  to  the  end,  as  many  as  are  needed 
for  that  side.  The  sutures  on  the  other  side  are  then  passed  in  the  same 
manner.  When  all  the  sutures  are  in  place  the  cervix  is  washed  off  with  the 
antiseptic  solution  and  all  clots  are  carefully  sponged  avray  from  the  angles 
of  the  tear.  The  sutures  are  then  tied,  beginning  with  the  one  first  passed. 
All  the  sutures  of  one  side  are  tied  and  then  those  on  the  other  side  (Fig. 
538).  The  line  of  approximation  is  then  examined  to  see  if  any  superficial 
sutures  are  needed.  Frequently  one  or  tw^o  superficial  sutures  will  be  needed 
to  secure  accurate  approximation.  The  sutures,  if  of  silkworm-gut,  are  then 
cut  long — about  an  inch  from  the  knots.  If  the  silkworm-gut  ends  are  cut 
shorter  they  are  likely  to  stick  the  vaginal  wall  and  cause  irritation.  If 
after  denudation  there  is  much  bleeding  from  the  denuded  angle  of  the  tear, 
the  suture  at  the  angle  may  be  tied  as  soon  as  passed. 

6.  Replace  the  uterus.  The  uterus  is  necessarily  pulled  down  a  good 
deal  during  repair  of  the  cervix  and  the  fundus  may  have  gone  backward. 
After  the  cervix  is  repaired  the  speculum  should  be  removed  and  the  uterus 
replaced  to  its  normal  position  by  bimanual  manipulation  (Fig.  568). 


618 


DISEASES   OF    THE   UTERUS 


A  Strip  of  antiseptic  gauze  is  then  packed  lightly  into  the  vagina  and 
the  vulva  is  covered  with  a  sterile  dressing  of  cotton  or  gauze,  held  in  place 
by  a  T-bandage. 

In  this  operation,  for  keeping  the  field  clear  of  blood,  the  author  em- 
ploys sponging  with  cotton-balls  wrung  out  of  bichloride  solution  (1-5000) 
and  held  in  long  forceps,  with  occasional  washing  out  with  the  hot  bichloride 


Fig.  537.     Denudation    Completed   and    Sutures    Passed   on   one    side.      (Kelly — Operative    Gynecology.) 

solution.     If  preferred,  continuous  irrigation  may  be  employed,  with  occa- 
sional sponging. 

For  suture  material  in  the  cervix,  the  author  prefers  silkworm-gut,  ex- 
cept when  the  pelvic  floor  is  to  be  repaired  at  the  same  time.  When  an  ab- 
sorbable suture  is  desirable,  and  chromicized  catgut  (that  will  last  twenty 
days,  preferably  more,  in  the  tissues)  is  satisfactory.  No  suture  is  advisable  here 
that  will  not  remain  at  least  ten  days  in  the  mucosa.  Even  when  the  pelvic  floor 
and  cervix  are  repaired  simultaneously,  it  is  often  just  as  well  to  use  silkworm-gut 
in  the  cervix  and  leave  it  in  place  four  to  six  weeks.  "When  the  pelvic  floor 
is  firmly  healed,  place  the  patient  in  the  Sims  posture,  carefully  introduce 
the  Sims  speculum  and  remove  the  cervical  sutures. 


OPERATION   FOR   LACERATION   OF    CERVIX   UTERI 


619 


If  trachelorrhaphy  is  carried  out  in  the  dorsal  posture,  there  is  no  dif- 
ficulty in  tying  the  sutures.  In  the  Sims  posture  there  may  be  considerable 
difficulty,  necessitating  the  use  of  perforated  shot  for  fastening  them. 

Silver  wire  is  good  suture  material  for  the  cervix,  but  it  is  no  better 
than  silkworm-gut  and  is  decidedly  more  inconvenient  to  handle. 

Silk  is  poor  suture  material  for  the  cervix  for  it  soon  becomes  soaked 
with  fluid  and  permeated  by  bacteria,  and  acts  as  an  irritant  in  the  tissues. 

When  there  is  a  stellate  laceration,  the  expedient  to  be  adopted  depends 
on  the  situation  and  extent  of  the  lacerations.  If  the  principal  laceration  is 
bilateral,  the  other  being  slight  and  consequently  of  little  importance,  the 
latter  may  be  disregarded.  If  the  third  laceration  is  deep  and  close  to  one 
of  the  lateral  tears,  the  small  intervening  piece  of  tissue  may  be  excised  and 
the  laceration  converted  into  a  simple  bilateral  one,  which  is  repaired  in  the 
usual  way.     When  the  third  tear  is  deep  and  near  the   center   of  the  an- 


Fig.   538.     Sutures  Tied — Operation   Coinpleted.      (Kelly — Operative   Gynecology.) 


terior  or  the  posterior  lip,  it  may  be  denuded  and  repaired  first,  and  then  the 
lateral  tears  repaired  as  usual.  Sometimes  in  a  bilateral  laceration  there  is 
a  marked  disproportion  between  the  lips,  one  lip  being  much  larger  than  the 
other,  making  accurate  approximation  impossible  by  the  usual  means.  When 
the  difference  is  not  marked  it  may  be  equalized  by  extending  the  angle 
of  excision  into  the  longer  lip.  When  the  disproportion  is  marked,  a  wedge- 
shaped  piece  may  be  excised  from  the  longer  lip  and  the  wound  closed,  and 
then  the  two  lips  approximated  by  the  ordinary  operation.  Another  method 
is  to  trim  down  the  large  lip  by  cutting  the  end  and  sides  and  inner  surface. 
That,  of  course,  leaves  no  mucous  lining  for  the  new  cervical  canal.  How- 
ever, an  extra  width  of  lining  for  the  new  canal  is  left  on  the  other  lip  and 
this  prevents  union  of  the  surfaces  where  the  canal  should  be.  If  the  lips 
are  greatly  hypertrophied  from  cystic  disease,  partial  amputation,  as  described 
below,  is  preferable  to  trachelorrhaphy. 

After-treatment.    The  genitals  should  be  kept  covered  with  a  large  sterile 


620  DISEASES   OF    THE   UTERUS 

dressing  of  cotton  or  gauze.  Do  not  eatheterize  the  patient  unless  there 
should  be  retention  of  urine. 

A  bowel  movement  should  be  secured  the  second  or  third  day,  and  daily 
after  that.  The  gauze  packing  may  be  left  in  two  days.  It  is  then  removed, 
and  thereafter  a  hot  bichloride  douche  (1-5000)  given  once  or  twice  daily, 
depending  on  the  amount  of  discharge. 

After  the  first  week,  the  patient  may  be  allowed  to  get  up  and  walk 
about,  as  rest  in  bed  after  the  first  few  days  is  not  necessary  for  the  healing 
of  the  cervix.  In  many  cases,  however,  it  is  best  to  keep  the  patient  in  bed 
two  or  three  weeks  for  the  benefit  of  associated  diseases.  In  "run-down," 
nervous  and  worn-out  women,  this  combination  of  the  rest-cure  with  the 
operation  is  of  gres^t  benefit,  and  in  some  of  them  the  rest  in  bed  with  good 
nourishment  and  relief  from  care,  probably  contributes  as  much  as  the  cer- 
vical repair  to  the  improvement  attained. 

The  sutures  are  removed  in  two  weeks.  The  most  convenient  way  to  re- 
move the  sutures  is  to  place  the  patient  in  the  Sims  posture,  introduce  the 
Sims  speculum,  expose  the  cervix,  catch  an  end  of  a  suture  with  forceps,  pull 
it  down  until  the  knot  comes  into  view  or  can  be  felt  with  the  point  of  the 
scissors,  and  then  cut  the  loop.  When  it  is  supposed  that  the  sutures  are  all 
out,  remove  the  speculum,  place  the  patient  in  the  dorsal  posture  and  make  a 
digital  examination  to  see  if  all  the  sutures  are  really  out.  A  suture  missed 
by  inspection  is  easily  felt  in  the  digital  palpation. 

Sexual  intercourse  should  be  postponed  till  six  weeks  after  the  sutures 
are  removed. 

Failure  to  secure  the  desired  result  from  the  operation  may  be  due  to : 

1.  Want  of  necessary  preparatory  treatment. 

2.  Infection,  which  of  course  spoils  the  operation  and  may  lead  to  seri- 
ous periuterine  infiammation. 

3.  Insufficient  removal  of  the  scar-tissue  in  the  angles,  or  the  leaving  of 
cysts  somewhere  in  the  area  of  denudation. 

4.  Too  much  encroachment  upon  the  area  left  for  the  cervical  canal,  caus- 
ing subsequent  stenosis  with  retention  of  contents  and  dilatation  above  the 
constricted  area. 

5.  An  incomplete  diagnosis.  Trachelorrhaphy  will  not  relieve  the  symp- 
toms of  lacerated  pelvic  floor,  prolapsus  uteri,  adherent  retroversion,  chronic 
salpingitis  or  the  various  other  diseases  that  may  exist  in  the  pelvis.  To  oper- 
ate for  a  lacerated  cervix  without  a  thorough  examination  and  diagnosis,  as 
is  done  in  some  cases,  is  to  invite  failure  and  disappointment. 

The  physician  is  often  asked  if  the  cervix  will  not  tear  again  at  the  next 
labor.  It  may  and  it  may  not.  Very  frequently  it  does  not  tear  to  any  con- 
siderable extent.  A  cervix  which  has  been  repaired  Avill  dilate  better  and 
be  less  liable  to  injurious  tear  than  one  that  is  the  seat  of  cystic  disease 
and  dense  scar-tissue. 


PARTIAL   AMPUTATION    OF    CERVIX   UTERI 


621 


Partial  Amputation 

When  many  small  cysts  have  formed  in  the  everted  and  infiltrated  sur- 
faces of  the  cervix,  as  shown  in  Figs.  539  and  541,  excision  of  the  cystic  area 
(partial  amputation  of  the  cervix)  is  preferable  to  regular  trachelorrhaphy. 
Of  course,  when  there  are  only  a  few  cysts  they  may  be  removed  in  the  reg- 


U 


Fig.  539.     Cross    section    of    a    Cervix    which    is    the    seat    of    "Cystic    Degeneration."      o.    Dilated  gland- 
cavities,  forming  small  cysts,     h.  The  cervical  canal.      (Pryor,  after  Cornil — Pelvic  Inflammation.') 


Fig.   540.      Section    of    Cystic    Cervix.       Notice    how    the    dilated    glands    extend    out    under    the    squamous 

epithelium   layer. 


622 


DISEASES    OF    THE    UTERUS 


ular  deim elation  for  repair,  but  when  the  "cystic  degeneration"  is  extensive, 
excision  of  the  whole  cystic  area  is  advisable.  The  line  of  excision  is  made 
superficial  or  deep,  as  necessary  to  include  the  cystic  i^ortion  of  the  cervix 
(Figs.  541,  542). 

Steps  in  the  Operation.  The  preparations  are  the  same  as  for  repair  of 
the  cervix  and  the  same  instruments  are  required.  When  the  cervix  is  ex- 
posed with  the  speculum,  it  is  grasped  with  tenaculum  forceps,  one  being 
fastened  in  the  anterior  lip  and  the  other  in  the  posterior  lip.  The  cervix 
is  then  split  on  each  side,  sufficiently  to  permit  access  to  the  cystic  area  of 
each  lip   (Fig.  543-J.).     In  a  deeply-lacerated  cervix  this  may  not  be  needed. 


Fig.  541.  Representing  Cystic  Degeneration  of  the  Cervix. 
This  shows  also  a  line  marking  the  area  to  be  excised  in  partial 
amputation  for  cystic  disease.  (Dudley — Practice  of  Gynecol- 
ogy.) 


Fig.  542.  Showing  the  line  to 
follow  in  Excision  of  the  Cystic 
Area — Called  also  "Partial  Ampu- 
tation" and  "Schroeder's  Opera- 
tion."     (Pryor — Gynecology.) 


An  incision  is  then  made  across  the  inner  surface  of  the  base  of  the  anterior 
lip,  extending  through  the  diseased  layer  (Fig.  543-5).  An  incision  is  then 
made  across  the  front  margin  of  the  anterior  lip  and  is  continued  down  in 
the  cervical  tissue  to  the  other  incision  just  mentioned  (Fig.  543-(7). 

The  tissues  lying  to  the  inner  side  of  the  knife  are  thus  removed,  and 
a  similar  procedure  is  carried  out  on  the  posterior  lip.  Sutures  are  then 
passed  in  the  anterior  lip  as  shown  in  Figs.  542  and  543-D,  bending  the  raw 
surface  on  itself,  so  that  the  two  portions  are  approximated  and  Avill  grow 
together.     Similar  sutures  are  passed  in  the  posterior  lip.     Any  raw  surfaces 


PARTIAL   AMPUTATION    OF    CERVIX   UTERI 


623 


Fisj.  S43.  Partial  Amputation  of  the  Cervix-  (Schroeder's  Operation).  A.  The  cervix  split  from 
side  to  side  so  as  to  allow  access  to  the  base  of  the  cystic  area.  B.  Making  the  incision  across  the  base 
of  the  cystic  area  in  the  anterior  lip.  In  the  posterior  lip  the  cystic  area  is  already  excised  and  some 
sutures  passed.  C.  Excising  the  cystic  area  in'  the  anterior  lip.  Also  trimming  the  posterior  lip  to  allow 
of  better  approximation.  D.  Both  cystic  areas  excised  and  the  tissues  trimmed  for  approximation.  This 
shows    also   the   method    of    suturing.      (Pryor — Gynecology.) 


624  -  ■     DISEASES    OF    THE    UTERUS 

left  at  the  sides  of  the  anterior  or  posterior  lips  are  closed  by  suturing  (Fig. 
544). 

This  operation  removes  most  of  the  diseased  tissue  and  reduces  the  size 
and  weight  of  the  cervix.  At  the  same  time  any  troublesome  scar-tissue  in 
the  angles  of  the  laceration  may  be  removed. 


Fig.   544.     Partial    Amputation    of    the    Cervix.      Sutures    Tied.      (Pryor — Pelvic   Inflammation.) 

IDIOPATHIC  HYPERTROPHY  OF  CERVIX 

The  term  "idopathie  hypertrophy"  of  the  cervix  is  applied  to  enlarge- 
ment of  the  cervix  independent  of  laceration  and  the  resulting  inflammation. 
As  this  form  of  hypertrophy  results  principally  in  elongation,  it  is  sometimes 
spoken  of  as  ''elongation  of  cervix."    It  is  a  rare  affection. 

Etiology,  Pathology,  Diagnosis 

The  cause  of  this  marked  increase  of  tissue  and  elongation  of  the  cervix 
is  not  definitely  kno%vn.  In  some  eases  of  prolapse  of  the  uterus,  the  vaginal 
walls  which  prolapse  at  the  same  time  drag  on  the  cervix  and  elongate  it, 
but  not  to  the  extent  here  contemplated.  It  may  occur  in  the  married  or 
unmarried.  It  occurs  oftenest  in  nullipara.  It  is  held  by  some  that  mas- 
turbation is  an  important  etiologic  factor,  as  it  is  in  hypertrophy  of  the  labia 
minora.  In  regard  to  age,  it  occurs  most  frequently  between  the  ages  of  fif- 
teen and  thirty-five. 

There  is  an  increase  of  tissue  in  the  cervix  but  in  such  a  way  that  the 
cervix  is  greatly  increased  in  length  without  a  corresponding  increase  in 
wddth.  If  the  hypertrophy  takes  place  only  in  the  vaginal  portion  of  the 
cervix,  it  presents  the  condition  sho^\-n  in  Figs.  279  and  280,  the  long  cervix 
projecting  along  the  vagina  or  even  outside  of  the  vagina  a  considerable 
■distance.     The  bodv  of  the  uterus  and  the  vaginal  walls  remain  in  approxi- 


CERVICAL   POLYPI  625 

mately  normal  position.  If  the  hypertrophy  is  confined  to  the  supravaginal 
portion,  the  vaginal  walls,  both  anterior  and  posterior,  are  pushed  down- 
ward by  the  same,  as  in  prolapse  (Fig.  281).  The  body  of  the  uterus,  how- 
ever, remains  in  about  the  normal  position.  If  the  hypertrophy  is  confined 
to  the  intermediate  portion,  the  anterior  wall  and  the  base  of  the  bladder 
will  be  pushed  down  as  in  prolapse,  the  posterior  wall  remaining  stationary 
(Fig.  282).  Retroversion  of  the  uterus  and  more  or  less  prolapse  are  usually 
present  also,  and  are  caused  by  the  dragging  of  the  heavy  cervix  and  the  vag- 
inal walls. 

The  patients  complain  of  dragging  weight  in  the  pelvis  and  of  a  pro- 
trusion at  the  mouth  of  the  vagina.  There  may  be  menstrual  disturbance  and 
leucorrhea. 

Examination  reveals  a  mass  with  the  characteristics  previously  mentioned. 
From  PROLAPSUS  uteri  it  is  distinguished  by  the  body  of  the  uterus  being 
in  approximately  normal  position.  From  uterine  tumor,  projecting  into  the 
vagina,  it  is  distinguished  by  its  form  and  by  its  central  cavity.  From  in- 
version of  the  uterus,  it  is  distinguished  by  the  body  of  the  uterus  being  in 
about  the  normal  position  and  by  its  central  opening. 

Treatment 

The  treatment  is  amputation.  The  preparations  for  amputation  and  the 
instruments  required,  are  the  same  as  for  repair  of  the  cervix. 

Regular  Amputation  of  Cervix 

In  this  operation  enough  of  the  cervix  is  amputated  to  reduce  it  to  the 
normal  size.  The  preferable  method  is  to  make  the  incision  in  the  form  of 
a  wedge,  as  shown  in  Fig.  545,  so  that  the  surfaces  will  approximate  well 
and  unite  without  excessive  scar  formation.  This  is  frequently  designated  as 
the  ''wedge-shaped"  amputation  of  the  cervix. 

The  long  cervix  is  first  split  laterally  into  an  anterior  and  posterior  lip 
(Fig.  546).  The  required  amount  of  tissue  is  then  removed,  as  shown  in  Fig. 
547.     The  sutures  are  then  introduced  (Fig.  547)  and  tied  (Fig.  548). 

The  after-treatment  is  the  same  as  for  trachelorrhaphy. 

CERVICAL  POLYPI 

Cervical  polypi  is  the  term  applied  to  small  non-malignant  tumors  found 
in  the  cervix  uteri.  They  are  usually  simple  adenomata  of  the  cervical  mu- 
cosa and  hence  are  frequently  designated  as  ''mucous  polypi."  Occasion- 
ally, a  small  fibromyoma  of  the  cervix  will  become  pediculated  and  project 
from  the  cervix,  constituting  a  polypus. 

The  principal  symptoms  are  bleeding  and  leucorrheal  discharge.     It  is 


626 


DISEASES   OF    THE    UTERUS 


J^^s^ 

^^r 

1 

^ 

M 

-ri 

w 

Fig.  545.  Regular  Amputation  of  the  Cervix. 
Showing  the  Wedge-shaped  Lines  of  Excision.  (Skene 
■ — Diseases    of    Women.) 


Fig.  546.     Amputation  of  the  Cervix.     First  step 
— splitting  the  cervix.     (Skene — Diseases  of  Women.') 


Fig.  547.     Regular  Amputation   of  the   Cervix.      Excision   of  tissue   completed   and   Sutures   passed. 

(Skene — Diseases  of   Women.) 


CERVICAL   POLYPI 


627 


Fig.   54S.      Sutures    tied,    operation    completed.       (Skene-^-Diseascs    of    Women.) 


Fig.  549.     Mucous    Polypi    of    the    Cervix.      (Hirst — Diseases    of    Women.) 


628 


DISEASES    OF    THE    UTERUS 


surprising  what  troublesome  and  persistent  bleeding  will  sometimes  be  oc- 
casioned by  a  small  polypus  in  the  cervix. 

On  digital  examination,  the  small  polypus  may  often  be  felt  as  a  small 
soft  mass  projecting  from  the  cervix  or  obstructing  the  external  os  (Fig. 
549).    In  some  cases  the  polypus  is  so  soft  that  it  is  not  noticed  on  palpation. 

In  the  examination  through  the  speculum,  the  polypus  is  seen  (when  low 
enough  in  the  canal)  as  a  small  rounded  red  mass,  projecting  from  the  ex- 
ternal OS  or  filling  the  os. 

The  important  thing  in  the  diagnosis  is  to  distinguish  beginning  malig- 
nant disease  from  simple  polypus.  Not  infrequently  in  malignant  disease  of 
the  cervix  small  projections  form  within  the  cervical  canal  and  appear  at  the 


Fig.   550.      Cross    section    of    a    fibrous    pob'pus    of    the    cervix    uteri. 

external  os,  presenting  almost  the  same  appearance  as  the  simple  polypus. 
Whenever  there  is  the  least  doubt  as  to  the  nature  of  the  polypus,  it  should 
after  removal  be  submitted  to  microscopic  examination.  Fig.  550  shows  a 
fibrous  polypus  of  the  cervix. 

The  treatment  is  removal.  The  little  mass  of  tissue  may  usually  be 
grasped  with  the  long  dressing  forceps  and  twisted  oif.  An  astringent-anti- 
septic application  is  then  made,  and  a  tampon  or  vaginal  packing  applied. 
If  there  is  much  bleeding  it  is  well  to  pack  the  cervical  canal  firmly  with  an- 
tiseptic gauze,  to  be  removed  in  forty-eight  hours. 


HYPERPLASIA  OF  ENDOMETRIUM 

Hyperplasia  of  the  endometrium  is  a  nutritive  change  and  is  always  chronic. 
In  its  various  forms  it  is  sometimes  designated  as  cartarrhal  endometritis,  hy- 


HYPERPLASIA   OF   ENDOMETRIUM  629 

pertrophic  endometritis,  fungous  endometritis,  polypoid  endometritis,  hem- 
orrhagic endometritis,  atrophic  endometritis,  chronic  endometritis,  pseudo- 
metritis.  Some  of  these  terms  are  used  to  express  particular  forms  of  hy- 
perplasia and  some  are  used  to  cover  all  forms  of  chronic  endometritis.  It 
is  a  decided  advantage  to  designate  a  disease  or  condition  by  some  name 
Avhich  will,  as  far  as  practicable,  express  the  distinctive  characteristics  of 
that  disease.  An  investigation  will  demonstrate  to  the  reader  that  the  names 
here  selected  out  of  the  mass  of  names  applied  to  the  inflammatory  and  nu- 
tritive disease  of  the  uterus,  express  clear-cut  clinical  entities — designated 
by  their  distinguishing  characteristics  and  covering  the  field  under  consider- 
ation without  troublesome  over-lapping. 

The  existing  confusion  between  hyperplasia  of  the  endometrium  and  the 
so-called  endometritis  is  chiefly  due  to  the  fact  that  heretofore  not  enough 
attention  has  been  paid  to  the  important  factor  of  the  cyclic  change  in  the 
histologic  picture  of  the  endometrium  from  one  menstruation  to  the  next. 
With  the  work  of  Hitschmann  and  Adler,  confirmed  in  all  its  essential  fea- 
tures by  all  the  later  investigators,  the  question  of  endometritis  has  entered 
a  new  stage.  A  sharper  line  can  be  dra\^Ta  between  the  changes  of  the  en- 
dometrium due  to  normal  ovarian  influence  finding  their  expression  in  the 
normal  menstrual  flow,  and  changes  of  a  pathologic  nature,  the  result  either 
of  abnormal  ovarian  function  or  of  an  infection,  usually  manifesting  them- 
selves in  the  form  of  menorrhagia,  or  metrorrhagia. 

Etiology 

The  cause  of  hyperplasia  of  the  endometrium  is  a  disturbance  of  the  nu- 
trition of  the  endometrium  without  the  intervention  of  bacteria.  This  nutri- 
tive disturbance  is  due  to  a  deficiency  in  the  quantity  or  quality  of  the  blood 
supplied  to  the  endometrium  or  to  special  cell  conditions.  The- particular  con- 
ditions that  tend  to  affect  the  endometrium  in  one  or  more  of  the  three  ways 
mentioned  are  as  follows: 

1.  General  diseases  or  extrapelvic  local  diseases  that  produce  marked 
anemia,  for  example,  chlorosis,  phthisis,  nephritis,  leukemia,  gastro-intesti- 
nal  affections  and  all  wasting  diseases. 

2.  General  diseases  or  extrapelvic  local  diseases  that  cause  metabolic  by- 
products and  other  abnormal  substances  that  circulate  in  the  blood.  Investi- 
gations, rather  extensively  carried  on  during  the  last  decade,  suggest  strongly 
an  influence  of  some  of  the  endocrine  glands  especially  of  the  ovaries  as  the 
result  of  functional  hyperactivity  in  the  causation  of  a  hyperplastic  condi- 
tion of  the  endometrium.  This  possible  etiologic  relation  is  discussed  in 
Chapter  xv. 

3.  Extrapelvic  diseases  or  conditions  causing  chronic  pelvic  congestion, 
for  example,  heart  disease  with  failing  compensation,  occupation  that  necessi- 
tate long  standing  or  excessive  walking  or  much  lifting. 


630  DISEASES    OF    THE    UTERUS 

4.  Pelvic  diseases  outside  the  uterus  causing  chronic  pelvic  congestion, 
for  example,  chronic  pelvic  inflammation,  pelvic  tumors  and  chronic  disease 
of  the  rectum  or  bladder. 

5.  Malpositions  of  the  uterus  that  interfere  with  the  circulation  of  blood 
in  the   endometrium — anteflexion,   retroflexion,  retroversion  and  prolapse. 

6.  Tumors  of  the  uterus  that  interfere  with  the  blood  circulation  of  the 
endometrium- — fibromyomata,  carcinomata  and  sarcomata. 

7.  Foreign  bodies  in  the  uterine  cavity,  that  keep  up  chronic  congestion 
and  irritation  of  the  endometrium,  for  example,  placental  remnants  left  af- 
ter an  abortion,  or  uterine  secretions  retained  by  stenosis. 

8.  Acute  simple  endometritis,  with  the  persistence  of  some  source  of  in- 
trauterine irritation. 

9.  Occasionally  by  mistake  a  hyperplasia  of  the  endometrium,  especially 
of  the  glandular  type,  is  diagnosed,  when  accidentally  during  a  curetment  the 
only  temporarily  hyperplastic  endometrium  of  the  premenstrual  stage  is 
removed. 

10.  When  the  uterine  wall  is  physiologically  hypertrophied  and  fails  to 
return  to  its  normal  condition — subinvolution. 

11.  Retrograde  cell  changes  as  seen  during  and  following  the  menopause, 
or  abnormal  cell  changes  as  in  a  poorly  developed  uterus,  both  possibly  as  the 
result  of  deficient  ovarian  function  (see  Chapter  xv).  Cases  of  uterine  in- 
flammation after  the  climacteric  originate  in  this  way,  and  later,  on  account 
of  the  discharge,  infection  may  take  place  and  acute  infected  endometritis 
appear. 

Pathology 

There  is  chronic  congestion  of  the  endometrium  and  of  the  adjacent  mus- 
cular tissue,  engorgement,  serous  and  cellular  infiltration  into  the  tissues,  and 
hyperplasia  of  the  tissue  elements  in  varying  proportion.  This  is  the  usual 
change.  In  some  cases,  however,  there  is  atrophy  and  shrinking  of  the  endo- 
metrium, instead  of  increase  in  thickness.  Either  form,  after  continuing 
many  years,  tends,  to  cirrhosis  of  the  uterus,  though  not  so  markedly  as  in- 
fected endometritis.  As  indicated  under  etiology,  a  hyperplastic  endometrium 
is  nearly  always  symptomatic  of  some  other  affection.  It  is  associated  with 
and  dependent  upon  some  other  disease,  and  yet  in  the  course  of  time  that 
causative  disease,  for  example  retroflexion,  may  be  so  far  surpassed  by  the 
symptoms  of  endometritis  as  to  be  of  secondary  importance. 

In  the  hypertrophic  form,  the  glands  increase  in  number  and  length  and 
there  may  be  hyperplasia  of  the  stroma  cells.  The  endometrium  becomes 
much  thickened  (Figs.  554,  555)  and  in  spots  the  surface  is  uneven  and  nodu- 
lar (fungous  endometritis).  Small  areas  of  this  cushion  of  hypertrophied 
tissue  project  from  the  general  surface  into  the  cavity.  One  of  these  pro- 
jections may  increase  until  it  becomes  pedunculated,  thus  forming  a  polypus 
(Fig.  556).    There  may  be  many  of  these  polypi,  forming  polypoid  endometri- 


HYPERPLASIA   OF   ENDOMETRIUM  631 

tis  (Figs.  552,  553).  This  presents  the  same  hemorrhagic  tendency  as  the 
infected  hypertrophic  endometritis,  to  be  mentioned  later.  There  is  in- 
creased secretion  from  the  glands,  causing  discharge.  The  gland  ducts  be- 
come obstructed,  causing  cysts.  When  the  endometritis  follows  abortion  or 
labor,  islands  of  decidual  tissue  may  persist  for  a  long  time  and  act  as  a  source 
of  irritation. 

In  the  atrophic  form,  the  change  presented  is  that  of  atrophy  of  the  es- 
sential tissue-elements,  leaving  the  connective  tissue  to  largely  occupy  the 
field.  The  number  of  glands  is  diminished  by  pressure  atrophy,  the  ducts 
of  some  of  them  becoming  obstructed  to  such  an  extent  that  cysts  form. 
The  cytogenic  tissue  also  is  diminished,  and  the  endometrium  becomes  un- 
able to  perform  its  function  of  menstruation  or  of  nourishment  of  the  fertil- 
ized ovum.  Of  course,  in  either  form,  infection  may  take  place,  and  then 
the  symptoms  of  infected  endometritis  are  added  to  those  of  simple  endo- 
metritis. 

Symptoms  and  Diagnosis 

The  symptoms  of  hyperplasia  of  the  endometrium  are  about  the  same 
as  of  chronic  infected  endometritis,  namely,  vaginal  discharge,  menstrual  dis- 
turbances, hemorrhagic  tendency,  backache,  dragging  weight  in  pelvis,  tired 
feeling,  sterility,  reflex  disturbances,  enlargement  of  uterus  and  increased  sen- 
sitiveness. The  number  and  extent  of  the  symptoms  will  depend,  of  course, 
upon  the  extent  of  the  pathologic  process  and  the  reaction  of  the  patient's 
nervous  system.  Hyperplasia  of  the  endometrium  differs  from  chronic  in- 
fected endometritis  in  the  following  particulars: 

a.  There  is  no  history  of  infection,  i.  e.,  of  acute  endometritis,  either  sep- 
tic or  gonorrheal.  This  hyperplastic  endometrium  is  the  form  of  endome- 
tritis found  in  girls  and  unmarried  Avomen  with  menstrual  disturbances  and 
in  married  women  who  have  never  had  any  infection.  It  is  frequently  found 
in  the  uninfected  uterus  which  is  the  seat  of  subinvolution  or  fibroids  or  ma- 
lignant disease  or  postclimacteric  inflammation. 

b.  The  discharge  is  usually  not  so  profuse  nor  so  irritating  and,  when 
taken  from  the  uterus,  it  contains  no  pathogenic  bacteria. 

c.  There  is  no  evidence  about  the  urethra  or  vulvo-vaginal  glands  of 
previous  infection. 

d.  Tubal  complications  are  very  rare. 

e.  There  is  nearly  always  some  associated  disease,  of  which  the  hyper- 
plasia of  the  endometrium  is  symptomatic  and  which  must  he  cured  before 
the  endometritis  will  subside. 

Treatment 

.  The  treatment  of  hyperplasia  of  the  endometrium  is  about  the  same  as  of 
chronic  infected  endometritis,  to  be  described  later.  The  following  points 
should  be  kept  in  mind : 


632  DISEASES    OF    THE   UTERUS 

1.  The  general  condition,  especially  the  quality  and  quantity  of  the  blood 
supplied  to  the  endometrium,  is  of  more  importance  and  consequently  the 
general  treatment  must  be  carefully  considered. 

2.  The  hyperplasia  is  dependent,  usually,  upon  some  other  disease  which 
must  be  corrected  before  the  condition  can  be  cured. 

3.  When  it  is  found  in  virgins,  or  suspected  from  the  symptoms,  attempt 
amelioration  by  general  treatment  (blood,  bowels,  kidneys,  muscular  system, 
skin,  gastro-intestinal  tract)  and  avoid  local  examination  or  treament,  ex- 
cept in  those  cases  where  the  urgency  of  the  symptoms  or  the  persistence  of 
the  affection  makes  local  treatment  necessary.  In  some  of  these  cases  the 
use  of  organo-therapeutic  preparations,  especially  ovarian  extracts,  yields  satis- 
factory results  (see  Chapter  xv).  General  measures  in  the  virgin  are  to  be 
tried  first.  If  they  fail,  then  local  measures  such  as  vaginal  douches  may  be 
added.  If  they  fail,  then  the  question  of  intrauterine  treatment  is  to  be  con- 
sidered. 

4.  In  virgins  intrauterine  applications  are  not,  as  a  rule,  advisable.  The 
vaginal  orifice  is  small,  the  cervical  canal  is  small  and  the  applications  are 
painful  and  unsatisfactory.  Beside  that,  the  nervous  shock  incident  to  the 
necessary  exposure  is  much  greater  in  the  virgin.    For  these  reasons  and  the 

■  additional  one  that  in  those  cases  in  which  intrauterine  treatment  is  required 
applications  alone  usually  fail,  the  author's  rule  is  to  begin  the  local  treat- 
ment in  virgins  by  giving  an  anesthetic  and  clearing  out  the  diseased  endo- 
metrium with  the  curet,  that  a  new  and  healthy  endometrium  may  develop 
under  better  conditions.  Frequently  all  local  applications  will  thus  be 
avoided.  If  further  intrauterine  treatment  is  required,  applications  may  be 
made  afterward  more  satisfactorily  and  with  less  pain  to  the  patient. 

If  applications  are  needed,  the  ones  mentioned  on  page  397  may  be  used. 
In  the  hemorrhagic  form,  copper  sulphate  solution  (10%),  tincture  of  iodine 
and  iodo-phenol  are  applicable.  In  the  atrophic  form  (the  most  stubborn  and 
painful  variety),  ichthyol  10%  to  50%  in  glycerine  has  produced  beneficial 
results.  Pure  ichthyol  is  sometimes  used.  It  is  well  in  the  atrophic  form  to 
combine  the  applications  with  drainage  by  antiseptic  gauze. 

In  patients  who  object  to  curetment  or  in  the  cases  in  which  the  endo- 
metritis is  so  mild  or  of  such  short  duration  that  it  will  probably  yield  to  appli- 
cations, the  following  course  of  treatment  may  be  employed :  A  few  days  after 
menstruation,  under  proper  antiseptic  precautions,  introduce  a  narrow  strip 
of  iodoform  gauze  into  the  uterus.  If  necessary,  dilate  the  cervix  slightly. 
Then  pack  the  upper  part  of  the  vagina  lightly  with  gauze.  At  the  end  of 
two  days  remove  the  gauze  and  cleanse  the  parts  carefully.  Then  make  an 
intrauterine  application  and  introduce  another  narrow  strip  of  gauze  into  the 
uterus  and  another  light  gauze  packing  into  the  upper  vagina.  At  the  end 
of  two  days  the  same  process  is  repeated.  This  may  be  kept  up  until  two  or 
three  days  before  the  next  menstrual  flow  is  expected. 


ACUTE    INFECTED    ENDOMETRIUM  633 

111  cases  where  the  uterine  discharge  is  free,  it  is  desirable  to  have  the 
gauze  all  in  one  strip  with  the  end  near  the  vulva,  and  direct  the  patient  to 
remove  the  gauze  the  next  day  after  it  is  introduced  and  then  take  a  hot 
antiseptic  douche  every  6  to  12  hours  until  the  next  intrauterine  application, 
which  is  made  every  two  or  three  days.  During  the  course  of  treatment  the 
patient  should  lie  down  a  large  portion  of  the  time  and  should  do  but  little 
walking  and  no  work.  If  decided  improvement  follows  this  course  of  treat- 
ment it  may,  if  necessary,  be  carried  out  in  one  or  two  succeeding  inter- 
menstrual periods.  If  there  is  no  decided  improvement  from  the  first  course 
of  two  or  three  weeks,  it  is  a  waste  of  time  to  try  it  longer.  Curetment  is 
then  necessary.  During  curetment,  if  the  uterus  is  in  backward  displaement 
it  should  be  brought  forward  into  normal  position,  if  practicable.  In  ante- 
flexion, which  in  virgins  is  very  frequently  associated  with  simple  endometri- 
tis, the  dilatation  incident  to  curetment  and  the  subsequent  intrauterine  gauze- 
packing,  tends  to  some  extent  to  overcome  the  flexion  and  the  resulting 
stenosis. 

The  removal  of  the  causative  disease  in  every  case  is  very  important, 
for  unless  it  is  removed  there  is  strong  probability  of  recurrence. 

5.  The  prognosis  is  better,  provided  the  causative  disease  can  be  removed, 
for  there  are  no  bacteria  to  keep  up  chronic  irritation  and  congestion  in  the 
uterus. 

ACUTE  INFECTED  ENDOMETRITIS 

This  is  acute  inflammation  due  to  bacterial  invasion  of  th'e  endometrium 
and  adjacent  tissues  in  a  uterus  not  recently  pregnant.  Metritis  and  endo- 
metritis in  the  recently  pregnant  uterus  (puerperal  sepsis)  is  an  obstetric 
subject. 

Under  the  above  title  are  included  the  changes  taking  place  deeper  in 
the  uterine  wall  (metritis)  as  well  as  those  strictly  in  the  endometrium. 

Etiology  and  Pathology 

This  is  usually  due  to  infection  with  the  gonococcus  as  ordinarily  this  is 
the  only  germ  that  will,  on  mere  contact,  implant  itself  and  grow  and  spread 
upward,  in  the  non-puerperal  genital  tract.  Gonorrhea  involves  the  cervix 
in  a  large  proportion  of  the  cases  of  vaginal  gonorrhea.  Its  extension  up- 
ward from  the  cervix  to  the  endometrium  may  be  spontaneous  or  induced. 
Spontaneous  extension  upward  may  take  place  immediately  folloAving  the 
infection  of  the  cervical  mucosa  or  the  inflammation  may  remain  limited  to 
the  cervix  for  weeks  and  months,  with  the  possibility  of  the  extension  up- 
ward at  any  time.  During  or  immediately  following  the  menstrual  flow  is 
the  favorite  time  for  the  progress  upward  of  the  gonococci.  This  fact  can 
in  many  cases  be  clearly  shown  by  questioning  the  patient  closely  as  to  just 
when  the   first  evidences   of   endometrial  infection  appeared.     Induced   ex- 


634  DISEASES   OF    THE    UTERUS 

tension  of  the  gonorrheal  infection  upward  may  be  caused  by  treatment  de- 
signed to  check  the  inflammation.  On  this  account,  in  all  local  treatment  of 
gonorrheal  endocervicitis,  great  care  should  be  taken  to  avoid  the  immedi- 
ate vicinity  of  the  internal  os.  Also,  sounding  of  the  uterus  or  other  intra- 
uterine instrumentation  in  cases  of  gonorrhea  of  the  cervix  (acute,  chronic 
or  latent),  is  likely  to  lead  to  gonorrheal  infection  of  the  endometrium.  In- 
fection of  the  endometrium  with  other  inflammatory  bacteria  (staphylococ- 
cus, streptococcus,  colon  bacillus,  etc.)  is  usually  due  to  examination  with 
a  sound  in  the  uterus  or  other  intrauterine  instrumentation,  the  germs  being 
carried  in  from  outside  the  body  or  from  the  vagina  or  from  the  cervical 
canal.  Endometritis  so  caused,  was  rather  frequent  formerly,  when  the  uter- 
ine sound  was  passed  by  touch,  but  not  so  now  since  the  uterus  is  not  so 
often  sounded,  and  when  it  is  sounded  care  is  taken  to  do  the  sounding  in 
an  aseptic  way.  Still,  in  some  cases  infectious  germs  lurk  in  the  cervix  with- 
out decided  symptoms,  and  in  spite  of  precautions  the  endometrium  may  be 
infected. 

Occasionally  the  ordinary  pus  germs  may  extend  upward  in  a  patho- 
logic discharge  (due  to  chronic  endometritis).  In  this  way  a  simple  endo- 
metritis may  eventuate  in  an  infected  endometritis,  without  the  intervention 
of  pregnancy  or  instrumentation.  This  is  probably  a  rare  occurrence  in 
the  presence  of  normal  functional  activity  and  normal  tissue  resistance.  The 
period  of  the  menopause,  however,  with  its  nutritive  disturbance  and  its  di- 
minished tissue  resistance,  seems  to  offer  exceptional  facilities  for  the  spon- 
taneous extension  upward  of  ordinary  pus  germs.  Hence,  the  form  of  acute 
endometritis  so  comparatively  frequent  in  the  aged,  and  producing  such 
special  conditions  (due  to  the  senile  condition  of  the  tissues)  that  it  has  been 
given  the  special  name  "senile  endometritis."  Senile  endometritis  may,  as 
explained  later,  be  either  simple  or  infected,  and  on  account  of  the  senile 
lowering  of  resistance  a  simple  endometritis  is  likely  to  become  an  infected 
one  by  spontaneous  extension  upward  of  pus  germs. 

Practically  the  whole  endometrium  is  involved.  The  germs  lie  on  the 
surface  and  also  penetrate  into  the  glands  and  into  the  interglandular  tis- 
sue. Later,  they  penetrate  into  the  underlying  muscular  tissue  to  a  greater 
or  less  extent.  There  are  the  usual  phenomena  of  inflammation,  congestion, 
swelling,  serous  and  cellular  infiltration  into  the  tissues,  and  a  muco-puru- 
lent  discharge  consisting  of  glandular  secretion,  serous  exudate,  dead  leuko- 
cytes and  exfoliated  epithelium,  with  occasionally  some  blood.  There  is  a 
marked  tendency  of  the  infection  to  spread  to  the  Fallopian  tubes. 

Symptoms  and  Diagnosis. 

In  the  gonorrheal  cases,  after  the  vaginitis  or  cervicitis  has  continued  a  few 
days  or  several  weeks,  as  the  case  may  be,  the  patient  complains  of  "cramps" 
in  the  lower  abdomen  and  of  soreness  in  the  pelvis  when  walking,  and  of 


ACUTE   IXFECTED   ENDOMETRIUM  635 

increased  vaginal  discharge.  Sometimes  the  pain  is  qnite  severe  and  occa- 
sionally the  patient  is  confined  to  bed  for  a  few  days.  There  may  be  moderate 
fever  (101°  to  102°),  but  the  fever  is  rarely  marked  as  in  puerperal  endome- 
tritis. By  close  questioning,  we  can  usually  obtain  a  history  of  symptoms 
indicating  gonorrhea  within  the  last  few  weeks  or  months. 

In  the  form  due  to  ordinary  pus  germs,  the  symptoms  are  about  the  same, 
with  a  history  of  some  local  treatment  (intrauterine  instrumentation)  or  of 
simple  endometritis,  causing  discharge,  in  which  the  germs  multiply  and  thus 
extended  upward.  If  there  is  any  discharge  from  the  urethra  or  vulvo-vaginal 
glands,  a  spread-preparation  of  it  is  made  on  a  cover-glass  or  slide,  which  can 
later  be  stained  and  examined  for  the  gonococcus. 

Digital  and  bimanual  examination  show  that  the  body  of  the  uterus  is 
tender  on  pressure.  If  the  disease  is  still  limited  to  the  uterus,  there  will  be 
no  decided  tenderness  outside  the  organ.  If  the  trouble  has  extended  to  the 
adnexa,  there  will  be  marked  tenderness  and  perhaps  a  mass  about  the  tube 
involved.  Through  the  speculum,  the  muco-purulent  discharge  may  be  seen 
coming  from  the  cervix.  Also,  the  condition  of  the  vaginal  walls,  as  to  whether 
or  not  they  are  still  inflamed  may  be  thus  determined. 

The  diagnosis  of  acute  endometritis  rests  upon  the  following  points: 

1.  Subjective  symptoms.  Moderate  pain  and  tenderness  of  recent  origm. 
in  the  lower  abdomen,  with  vaginal  discharge  and  some  fever. 

2.  Tenderness  of  body  of  uterus  on  bimanual  examination. 

3.  Muco-purulent  discharge  coming  from  the  uterus,  as  shown  by  speculum 
examination. 

4.  Absence  of  other  evident  lesion  to  account  for  symptoms.  Corrobo- 
rative of  this  diagnosis,  is  a  history  of  recent  vaginal  inflammation  or  objective 
evidence  of  the  same  or  of  inflammation  of  the  urethra  or  vulvo-vaginal  glands 
or  cervix.  The  diseases  that  cause  confusion  in  diagnosis  are:  acute  vaginitis, 
acute  endocervicitis,  acute  pelvic  inflammation  and  hemorrhage  in  the  pelvis. 

In  ACUTE  VAGINITIS,  there  is  little  or  no  pain  or  tenderness  in  the  lower  abdo- 
men, the  uterus  is  not  particularly  tender  on  bimanual  examination  (the  ten- 
derness being  in  the  vaginal  walls),  and  speculum  examination  shows  enough 
inflammation  of  vaginal  walls  to  account  for  the  symptoms  (soreness  and  dis- 
charge.) 

In  ACUTE  ENDOCERVICITIS,  there  is  little  or  no  tenderness  in  lower  abdomen, 
the  body  of  uterus  is  not  particularly  tender  on  bimanual  examination  and 
speculum  examination  shows  a  profuse  glairy  discharge  from  the  cervix. 

In  ACUTE  PELVIC  INFLAMMATION,  the  pain  is  more  constant  and  sharp  and  ex- 
tends more  into  the  sides.  Bimanual  examination  shows  that  the  tenderness  is 
situated  about  the  adnexa  of  one  or  both  sides,  instead  of  in  the  body  of  the 
uterus.  Also,  there  is  usually  some  indication  of  a  mass  of  exudate  to  one  side 
of  the  uterus. 

Of  course,  any  one  of  the  three  diseases  just  mentioned  may  be  found  with 


636  DISEASES    OF    THE    UTERUS 

an  acute  endometritis  and  then  the  symptoms  will  be  intermingled.  After  having 
established  the  fact  that  the  patient  has  an  acute  endometritis,  the  next  thing  to 
do  is  to  decide,  if  practicable,  what  kind  of  an  endometritis  it  is — whether  gonor- 
rheal or  ordinary.  If  we  can  find  nothing  to  indicate  that  the  trouble  is  gonor- 
rheal, we  assume  that  it  is  caused  by  the  ordinary  pus  germs.  In  questioning 
the  patient  as  to  evidence  of  gonorrhea,  it  is  well  in  all  but  exceptional  cases  to 
avoid  arousing  her  suspicions  that  the  trouble  may  be  such.  Such  suspicion  on 
her  part  will  do  no  good  and  may  do  much  harm. 

The  points  indicating  that  the  trouble  is  gonorrheal  are : 

a.  History  pointing  to  recent  gonorrhea,  particularly  symptoms  pointing 
to  acute  vaginitis  and  metritis  without  other  cause. 

b.  Evidences  of  previous  inflammation  of  urethra  (redness  and  pouting-out 
of  urethral  mucous  membrane  at  meatus  and  tenderness  about  urethra)  or  previ- 
ous inflammation  of  a  vulvo-vaginal  gland  (redness  about  opening,  discharge 
from  duct  and  induration  and  tenderness  of  gland) . 

c.  Acute  or  chronic  endocervicitis  without  cause. 

d.  Gonococci  found  in  discharge  from  urethra  or  vulvo-vaginal  glands  or 
cervix  or  endometrium. 

e.  Trouble  coming  on  shortly  after  marriage  wdthout  apparent  cause. 

f.  In  doubtful  cases  it  is  well  to  send  for  the  husband  (without  the  wife 
knowing  it)  and  ascertain  from  him  if  he  has  any  evidence  of  gonorrhea,  new  or 
old. 

Treatment 

No  abortive  or  quickly  curative  treatment  for  gonorrheal  or  other  acute 
forms  of  endometritis  has  been  found.  There  is  no  probability  of  immediately 
dangerous  absorption  from  the  uterus  (as  in  puerperal  endometritis),  but  there 
is  great  probability  of  the  inflammation  becoming  chronic  and  persisting  for 
months  or  years,  and  sooner  or  later  involving  the  tubes.  In  many  cases  tubal 
complications  develop  in  spite  of  the  most  careful  treatment,  though  the  treat- 
ment undoubtedly  helps  to  prevent  such  complications  in  other  cases.  The 
principal  factor  in  preventing  the  bacterial  invasion  is  the  resisting  power  of  the 
tissues.  The  treatment  should  be  of  such  character  as  to  increase  this  tissue 
resistance  and  at  the  same  time  lessen  the  irritation  in  and  about  the  infected 
uterus. 

General  Measures.  The  pelvic  congestion  and  the  pain  should  be  relieved 
as  far  as  possible  by  general  measures.  The  patient  should  be  put  to  bed,  if 
she  is  not  there  already,  and  kept  in  bed  until  the  acute  symptoms  subside.  Open 
the  bowels  well  by  some  reliable  purgative  and  then  maintain  one  or  two  move- 
ments daily  by  a  laxative,  for  example,  one  or  two  teaspoonfuls  of  Kochelle  salt 
each  morning  in  a  glass  of  water  one  hour  before  breakfast.  Enemata  should  be 
avoided  in  gonorrhea  on  account  of  the  danger  of  carrying  the  infection  into  the 
rectum.    If  there  is  much  pain  in  the  lower  abdomen,  use  hot  stupes  or  the  hot- 


ACUTE   SIMPLE   ENDOMETRITIS  637 

water  hag.  If  this  does  not  give  relief,  use  the  ice  bag.  If  the  pain  is  still 
troublesome  or  if  the  patient  is  restless,  give  mild  sedatives  internally. 

Vaginal  Douches  and  Applications.  The  hot  vaginal  douche,  given  accord- 
ing to  the  special  directions  in  Chapter  in,  clears  the  irritating  discharge  from  the 
vagina  and  diminishes  the  pelvic  soreness.  It  should  be  a  weak  antiseptic  solu- 
tion, the  same  as  recommended  in  gonorrheal  vaginitis.  The  length  of  the  inter- 
val between  douches  will  depend  on  the  amount  of  remaining  vaginitis  and  the 
amount  of  uterine  discharge.  Ordinarily,  if  the  vaginal  inflammation  has  about 
disappeared,  every  six  hours  will  be  often  enough  for  the  vaginal  douche.  If  there 
is  still  decided  vaginitis,  the  silver  nitrate  or  protargol  application  and  other 
measures  for  gonorrheal  vaginitis  are  indicated. 

No  intrauterine  treatment  is  advisable  in  acute  non-puerperal  endometritis, 
whether  gonorrheal  or  otherwise.  Many  kinds  of  intrauterine  treatment  have 
been  tried — intrauterine  irrigation,  intrauterine  applications  (weak,  strong  and 
medium),  intrauterine  packings  (medicated  and  unmedicated  for  drainage), 
caustics  and  curetment — and  all  apparently  increase  rather  than  diminish  the 
chance  of  extension  upward,  which  is  the  great  danger.  If  it  is  apparent  that 
the  uterine  cavity  is  not  draining,  i.e.,  that  there  is  retention  of  pus  within,  then 
the  cervical  canal  should  be  dilated  sufficiently  and  a  small  rubber  tube  inserted 
for  drainage.  It  should  be  arranged  so  that  it  will  not  slip  out,  for  it  is  im- 
portant that  the  drainage  be  free  and  constant.  With  free  drainage  and  the 
carrying-out  of  the  other  measures  mentioned,  we  have  assisted  Nature  to  the  full 
extent  of  our  ability  in  preventing  extension  upward  to  the  tube  or  outward 
through  the  uterine  wall  to  the  parametrium.  Free  drainage  removes  the  pus  as 
formed,  and,  as  already  explained,  the  use  of  any  intrauterine  instrument  what- 
ever is  likely  to  stir  up  irritation  and  increase  penetration  of  bacteria  and  do 
more  harm  than  it  can  do  good.  The  use  of  soft  suppositories  containing  a  suit- 
able antiseptic  may  eventually  prove  of  real  benefit  in  these  cases  (see  page  394). 

ACUTE  SIMPLE  ENDOMETRITIS 

This  term  is  aiDplied  to  certain  acute  changes  resembling  acute  inflammation 
that  appear  in  the  uterine  mucosa  without  bacterial  invasion. 

Etiology,  Pathology,  Symptoms 

This  is  a  nutritive  change  and  is  due  to  pronounced  acute  congestion  of 
the  uterine  mucosa,  which  is  usually  due  to  some  acute  disease  such  as  pneumonia 
or  typhoid  fever  or  scarlet  fever  or  to  some  severe  shock  to  the  nerves  of  the  skin, 
as  by  an  extensive  burn  or  prolonged  exposure  to  the  cold  or  heat,  or  to  suppres- 
sion of  the  menses.  Because  of  its  frequent  association  with  some  of  the  ex- 
anthematous  diseases  it  is  sometimes  called  " exanthematous  endometritis." 

In  some  cases  of  the  affection  mentioned,  there  is  intense  congestion  of  the 
uterine  mucosa,  swelling  of  the  tissues,  serous  or  cellular  exudate  on  the  surface 


638  DISEASES    OF    THE   UTERUS 

and  out  into  the  tissues,  exfoliation  of  the  cells  on  the  surface  and  in  the  glands, 
and  hemorrhage  onto  the  surface  and  into  the  tissues. 

The  trouble  is  primarily  uterine  congestion,  but  sometimes  the  changes  men- 
tioned persist  long  after  the  congestion  has  subsided.  The  process  may  be  ac- 
companied with  increased  discharge,  much  pain  and  the  usual  symptoms  of  mild 
acute  endometritis.  This  afifection  is  rare  but  it  is  important  as  indicating  that 
symptoms  of  acute  inflammation  may  be  present  without  infection — simply  as  a 
congestive  and  nutritive  change. 

Treatment 

The  treatment  is  to  keep  the  patient  quiet,  remove  the  causative  affection  as 
far  as  possible,  relieve  the  pelvic  congestion  by  purgatives,  and  give  vaginal 
douches  if  there  is  troublesome  discharge.  If  the  trouble  is  due  to  suppression 
of  the  menses,  hot  sitz-baths  and  hot  applications  and  hot  douches  are  indicated, 
as  described  in  Chapter  xiv.  Sedatives  should  be  given  as  required  to  relieve 
pain.  It  is  important  to  avoid  all  intrauterine  instrumentation,  for  the  condition 
of  the  interior  of  the  uterus  favors  infection.  If  the  patient 's  general  health  is 
restored,  the  disturbed  endometrium  usually  takes  care  of  itself,  the  damaged 
cells  being  cast  off  and  normal  conditions  restored.  Occasionally  some  source  of 
intrauterine  irritation  may  remain  and  cause  a  chronic  simple  endometritis. 

CHRONIC  ENDOMETRITIS 

This  is  chronic  inflammation  of  the  uterus  due  to  bacterial  invasion.  The 
different  germs  have  been  mentioned  when  speaking  of  the  various  forms  of  the 
acute  stage  of  bacterial  invasion  of  the  uterus.  Chronic  infected  endometritis 
is  known  in  its  various  forms  as :  chronic  endometritis,  chronic  metritis,  chronic 
catarrh  of  uterus,  chronic  gonorrheal  endometritis  and  chronic  septic  endo- 
metritis. 

Etiology  and  Pathology 

Chronic  infected  endometritis  follows  acute  infected  endometritis  (either 
gonorrheal  or  septic).  In  some  of  the  cases  of  acute  inflammation  of  the  uterus, 
the  process  does  not  disappear  after  the  acute  symptoms  subside  but  remains 
for  months  and  years,  causing  troublesome  leucorrhea  and  menstrual  disturbances. 

In  the  uterine  tissues  the  serous  infiltration  of  the  acute  inflammation  is 
largely  absorbed,  but  the  cellular  infiltration  remains  to  a  considerable  extent 
and  there  is  connective  tissue  formation.  The  germs  keep  up  a  constant  irritation 
in  the  tissues,  leading  to  chronic  hyperemia  of  the  endometrium,  and  adjacent 
tissues.  This  chronic  irritation  and  the  increased  blood  supply  causes  hyperplasia 
of  all  the  tissue  elements.  The  cellular  infiltration  combined  with  the  hyperplasia 
of  the  fixed  tissue  elements  causes  thickening  of  the  endometrium.  The  infecting 
germs  lie  upon  the  surface  and  in  the  glands  and  in  the  interglandular  tissue  and 


CHKONIC   ENDOMETRITIS 


639 


even  in  the  underlying  muscular  tissue.  The  chronic  hyperemia  gives  rise  to  in- 
creased secretion  from  the  glands,  and  this  secretion  combines  with  the  leukocytes 
and  epithelial  cells  and  micro-organisms,  and  forms  a  muco-purulent  discharge 
which  as  it  passes  through  the  cervix  becomes  associated  with  the  tenacious 
mucus  of  that  locality.  The  germs  may  disappear  entirely  after  several  months 
or  several  years,  but  the  changed  tissue  then  present  may  act  as  an  irritant  and 
keep  up  the  inflammation  as  a  simple  endometritis.  In  fact,  it  is  held  by  some 
that  in  ordinary  chronic  infected  endometritis,  the  micro-organisms  play  only  a 
small  part. 

The  congestion  and  the  described  condition  of  the  mucosa  usually  give  rise 
to  a  hemorrhagic  tendency.    The  hypertrophy  or  hyperplasia  may  progress  to  such 


Fig.  551. 


A   Normal    Uterus    divided    from    in    front,    showing   the    Smoothness    of   the    Endometrium   and 
also   its   relative   Thickness.      (Cullen — Cancer  of   the    Uterus.) 


an  extent  that  the  mucosa  becomes  many  times  its  usual  thickness.  "When  the 
hyperplasia  is  so  marked,  it  usually  takes  place  unevenly,  so  that  the  surface 
is  rough  and  nodular,  giving  rise  to  the  name  "fungous"  endometritis.  The 
normal  endometrium  is  shown  in  Fig.  551.  Chronic  endometritis  of  the  fungous 
form  is  shown  in  Figs.  552,  553.  In  this  condition  the  hemorrhagic  tendency  is 
a  marked  feature,  hence  the  name  "hemorrhagic"  endometritis.  In  some  cases 
the  masses  project  out  from  the  surface  and  become  pediculated  and  give  rise  to 
polypi.  This  condition  is  known  also  as  "polypoid"  endometritis  (Fig.  556). 
The  gland  ducts  become  obstructed  and  retention  cysts  are  thus  formed.    In  the 


640  DISEASES    OF    THE    UTERUS 

fungous  and  polypoid  form  of  endometritis,  the  interstitial  tissue  in  the  endome- 
trium undergoes  decided  increase  and  hence  the  condition  is  sometimes  designated 
interstitial  endometritis,  in  contradistinction  to  glandular  endometritis,  in  which 
there  is  marked  proliferation  of  the  glands  without  corresponding  increase  in  the 
connective  tissue.  Recent  investigations,  however,  show  that  the  glandular  type 
of  so-called  endometritis,  in  reality,  only  represents  the  normal  or  inflamed  endo- 
metrium in  its  premenstrual  appearance.  After  a  long  time  the  cellular  infiltra- 
tion largely  disappears,  new  connective  tissue  taking  its  place,  and  this  connective 
tissue  contracts  as  the  infiltration  cells  between  the  fibers  disappear.  The  glands 
are  thus  injuriously  pressed  upon  and  begin  to  undergo  pressure-atrophy,  their 
ducts  are  obstructed  and  cystic  dilatation  takes  place.  This  process  becomes  more 
and  more  marked  until  there  is  great  destruction  of  gland  tissue  and  the  condi- 
tion passes  into  sclerosis  of  the  uterus,  described  later,  in  which  little  remains  of 
the  mucosa  but  scar-tissue.  The  change  from  ordinary  chronic  endometritis  to 
the  condition  of  sclerosis  takes  several  years,  except  in  those  cases  in  which  the 
process  is  hastened  by  the  use  of  destructive  applications  within  the  uterus. 

Symptoms 

The  patient  comes  complaining  of  a  vaginal  discharge  (leucorrhea)  Avhich 
she  has  had  for  several  months  or  years,  as  the  case  may  be.  This  may  be  the  only 
symptom.  Usually,  however,  there  are  marked  menstrual  disturbances — painful 
menstruation,  increased  menstrual  flow  and  frequently  irregular  menstruation. 
When  hypertrophy  of  the  endometrium  is  a  marked  feature  of  the  endometritis, 
the  hemorrhagic  tendency  is  likewise  marked.  The  menses  may  last  a  week  or 
ten  days,  and  bleeding  between  times  may  appear.  Hemorrhage  is  especially 
marked  in  the  fungous  or  polypoid  condition  of  the  endometrium.  A  polypus 
thus  formed,  may  give  rise  to  sudden  serious  uterine  hemorrhage.  Occasionally 
the  menstrual  flow  is  diminished,  but  usually  not  unless  atrophic  changes  are 
present. 

Backache  and  weight  in  the  pelvis  and  dragging  pains  very  frequently 
accompany  endometritis.  The  patient  tires  easily  and  can  not  do  the  work  nor 
the  walking  that  she  formerly  could.  All  these  symptoms  are,  as  a  rule,  much 
worse  than  during  the  menstrual  period.  Sterility  is  usually  present  if  the  endo- 
metrial changes  are  marked.    Reflex  disturbances  may  also  appear. 

There  are  often  also  more  severe  symptoms  due  to  some  associated  affection, 
such  as  salpingitis  or  malposition  of  the  uterus.  By  questioning  the  patient  it 
can  usually  be  determined  whether  the  acute  infection  was  gonorrheal  or  ordinary 
septic  inflammation.  The  questioning  should  always  be  conducted,  of  course, 
in  such  a  way  as  not  to  arouse  the  patient's  suspicion  of  disease  in  her  husband. 
If  the  process  has  continued  long,  the  uterus  is  generally  increased  in  size,  par- 
ticularly so  when  the  infection  followed  labor  or  abortion,  with  resulting  subinvo- 
lution.   In  the  examination,  search  should,  of  course,  be  made  for  tubal  compli- 


CHRONIC    ENDOMETRITIS 


641 


cations  and  other  associated  diseases.     If  salpingitis  is  present,  it  shows  that 
infection  has  extended  to  the  endometrium  and  thence  to  the  tnbe. 

On  speculum  examination,  it  is  seen  that  the  discharge  comes  from  the  uterus, 
for  it  is  found  about  the  external  os  and  in  the  cervical  canal.  The  amount  of 
discharge  coming  from  the  uterus  may  be  determined,  if  desired,  by  placing  a 
tampon,  against  the  cervix  and  removing  it  after  twelve  to  twenty-four  hours. 
In  chronic  endometritis  the  discharge  may  be  slight  or  free,  and  it  is  usually 


Fig.  552.  Chronic  Endometritis,  polypoid  or  fungus  form.  The  area 
from  which  the  magnified  portion  (Fig.  553)  was  taken  is  indicated  at  z. 
(Cullen — Cancer   of  the    Uterus.) 


Fig.  553.  A  Section  from 
the  uterus  shown  in  Fig.  552 
highly  magnified.  (Cullen — 
Cancer   of   the    Uterus.) 


mixed  with  cervical  mucus.  There  is  more  discharge  than  can  be  accounted 
for  by  the  cervical  lesions  present.  If  the  uterine  sound  be  introduced,  the 
interior  of  the  uterus  is  usually  more  sensitive  than  usual,  bleeds  more  easily 
and  is  slightly  increased  in  size — but  sounding  is  rarely  advisable. 

The  diseases  which  are  most  likely  to  be  confused  with  chronic  infected 
endometritis  are  as  follows : 

Endocervicitis.     In  endocervicitis,  the  cervix  presents  evidence  of  inflam- 


642 


DISEASES    OF    THE   UTERUS 


mation  enough  to  account  for  tlie  discharge,  and  there  is  no  enlargement  or 
tenderness  of  the  uterus  or  evidence  of  tubal  inflammation. 

Chronic  Simple  Endometritis  or  Endometrial  Hyperplasia.  In  this  there 
is  no  infection  of  the  uterus  and  no  tubal  infection  of  intrauterine  origin. 
"Endometritis"  in  a  virgin  is  almost  always  of  this  character. 

Subinvolution  without  infection,  presents  a  large  uterus  with  discharge  and 
menstrual  disturbance,  but  without  any  history  of  infection. 

Tuberculosis  of  uterus.  In  this  there  are  usually  evidences  of  tubercular 
disease  of  the  tubes  and  pelvic  peritoneum.  It  resists  the  treatment  for  endo- 
metritis, and  tubercle  bacilli  are  found  in  the  discharge  or  scrapings,  or  in 
tissues  removed  by  curetment. 


•- 

■t          l_~..< 

'^;#  %p 

-"*% 

% 

'^'^"/■^^v 

i     ~^' 

\ 

i 

7~ 

■V        I 

^  ~-J.         •< 

1 

Fig.    554. 


Glandular    Hyperplasia     of 
Endometrium. 


Fig.   555.     Part  of  section  shown  in  Fig.  554,  under 
higher   power. 


Malignant  disease  of  the  endometrium.  In  malignant  disease,  the  apparent 
endometritis  does  not  yield  to  regular  treatment,  and  when  the  uterus  is  cleared 
out  with  a  curet  and  the  scrapings  examined  microscopically,  malignant  infil- 
tration is  found. 


Treatment 

1.  General  Measures.  The  patient  should  rest  in  bed  as  much  as  possible 
during  the  menstrual  periods  and  also  during  any  acute  exacerbation  of  the 
trouble.  Use  purgatives  and  laxatives  sufficiently  to  keep  the  bowels  well  open. 
Ergotin  and  hydrastis  have  some  affect  on  the  uterus  and  are  indicated  in  hem- 


TREATMENT   OF    CHRONIC   ENDOMETRITIS 


643 


orrhagic  conditions  and  in  hypertrophy.  For  the  relief  of  pain  at  the  menstrual 
period  or  at  other  times,  the  sedative  measures  mentioned  under  Dysmenorrhea 
are  employed.  Sitz-baths  taken  just  before  retiring  often  give  much  relief  to 
those  patients  complaining  of  pain  in  the  back  and  sacrum  and  pelvis  and  down 
thighs,  worse  at  the  close  of  the  day. 

Look  for  any  extragenital  disease  requiring  atteiition.  Put  the  patient 
in  the  best  possible  general  health.  Correct  any  dyscrasia  present.  Poor 
blood  from  general  diathetic  disease  often  tends  to  keep  up  chronic  inflam- 
mation in  the  uterus. 

2.  Hot  Vaginal  Douches.  These  should  be  given  one  to  three  times 
daily,  depending  on  the  amount  of  discharge  and  the  amount  of  pain.  The 
necessary  details  are  described  in  Chapter  ni  (page  354). 

3.  Intrauterine  Applications.  In  cases  in  which  the  inflammation  is  not 
severe,  intrauterine  applications  may  be  of  benefit.  In  the  hemorrhagic  form, 
the  hemorrhage  may  be  lessened  temporarily  by  these,  as  may  also  the  muco- 


Fig.  556.     Hyperplasia    of    Endometrium    which    has    progressed    to    polypoid    formation. 

purulent  discharge.     The  details  of  intrauterine  applications  are  explained 
in  Chapter  hi  (page  391).    The  following  medicines  may  be  used: 

Argent,  nitrat.,  4%  to  20%. 

Protargol,  2%  to  10%. 

Carbolic  acid. 

Tinct.  Iodine. 

Carbolic  and  Tinct.  Iodine,  half  and  half. 

Copper  sulphate,  10%. 

Formol,  10%  to  40%. 
These  applications  to  the  endometrium  may  be  made  once  a  week.    Af- 
ter the  application,  place  a  tampon  soaked  in  protargol-glycerine  or  ichthyol- 


644 


DISEASES    OF    THE   UTERUS 


glycerine  against  the  cervix.  Then  instruct  the  patient  to  lie  down  for 
several  hours  when  she  gets  home,  and  remove  the  tampon  at  the  next  douche 
time. 

Uterine  pencils  or  bougies  of  protargol  or  of  alum  and  iodoform  may  be 
used  (page  396). 

When  using  strong  applications,  such  as  carbolic  acid  or  iodo-phenol,  it 
is  well  to  introduce  a  small  sized  cervix  speculum  past  the  internal  os  and 
make  the  application  through  it,  to  prevent  the  liquid  being  squeezed  out  in 
the  cervix  and  producing  a  cauterizing  effect  with  resulting  stenosis  at  the 
internal  os. 

4.  Curetment.  If  a  short  course  of  treatment  by  intrauterine  applications 
does  not  produce  decided  benefit,  it  should  be  discontinued  and  some  more 
radical  means  employed. 

Curetment  for  Chronic  Endometritis 

In  a  large  number  of  the  cases  of  chronic  endometritis,  curetment  is  ad- 
visable as  the  first  step  in  the  treatment.     In  deep-seated  chronic  inflamma- 


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Fig.  557.  Instruments  for  Curetment:  a,  Edebohl's  self-retaining  speculum;  b,  vaginal  dressing- 
forceps,  for  cleansing  vagina;  c,  long  tenaculuni-f creeps,  for  holding  cervix;  d,  uterine  dressing-forceps, 
for  swabbing  within  uterus;  e,  uterine  sound  (the  bulbous  end  does  not  show  distinctly  in  the  photograph); 
/,  small  uterine  dilator;  g,  large  uterine  dilator  (Wathen's) ;  Ii,  sharp  uterine  curet  with  flexible  shank, 
large  size;  i,  sharp  uterine  curet,  small  size;  /,  short  scissors  for  cutting  gauze.  If  a  piece  from  the  cervix 
is  to  be  excised  for  microscopic  examination,  add  a  long  sharp-pointed  scissors  and  suture  material  and 
needles  and  a  needle-holder. 


OPERATION   FOR    CHRONIC    ENDOMETRITIS 


645 


tioii  of  the  uterus,  there  is  a  large  amount  of  thickened  tissue  (Figs.  552,  553) 
which  must  be  removed.  In  these  severe  cases,  it  is  a  waste  of  time  to  make 
applications  or  irrigations  before  this  is  done,  as  they  do  not  penetrate  the 
diseased  mucosa  sufficiently  to  do  any  good.     The  curet  removes  the  bulk  of 


Fig.  558. 


A  Kitchen  Table  Arranged  for  Curetment  or  other  vaginal   operation, 
can  be  carried  in  the  satchel  and  are  very  convenient. 


The  portable  leg-holders 


this  diseased  tissue.    Then,  if  necessary  later,  applications  may  be  made  with 
the  prospect  of  getting  a  decided  eifect  from  them. 

The  preparations  for  curetment  are  the  same  as  for  repair  of  the  pelvic 
floor.  The  instruments  required  are  shown  in  Fig.  557.  If  it  is  desired  to 
cleanse  the  uterine  cavity  by  irrigation,  instead  of  swabbing,  add  an  intra- 


646 


DISEASES    OF    THE    UTERfS 


uterine  irrigating  tube.  If  a  piece  of  the  cervix  is  to  be  excised  for  micro- 
scopic examination,  add  a  long  sliarp-pointed  scissors,  tAvo  strong  cervix  nee- 
dles, a  needle-liolder  and  suture  material. 

If  the  operation  is  to  be  done  at  the  patient's  home,  a  kitchen  table  is 
arranged  for  it,  as  shov.m  in  Fig.  558. 

Steps  in  the  Operation.  1.  The  patient  is  anesthetized  and  placed  in  the 
dorsal  posture,  with  the  feet  in  the  upright  supports  and  the  hips  at  the 
edge  of  the  table  (Fig.  559).     The  external  genitals  and  adjacent  surfaces  are 


Fig.   S59.     The  patient  in  position   at  the  end   of  the  table.      After  the  patient  is   anesthetized,   the   feet   are 
fastened  in  the  leg-supports  and  the  hips  are  brought   over  the  end  of  the  table. 


thoroughly  scrubbed  Chaving  been  shaved  in  the  preparation  before  anes- 
thesia) with  boiled  Avater  and  some  liciuid  preparation  of  green  soap,  using 
pieces  of  absorbent  cotton  or  a  very  soft  brush.  Then  the  vagina  is  vigorously 
cleansed  with  the  soap  solution,  using  cotton-balls  held  in  long  forceps  and 
introducing  two  fingers  into  the  vagina  to  spread  out  the  walls  and  smooth 
out  the  depressions  so  as  to  permit  thorough  cleansing  of  the  walls  (Figs. 
560,  561).     Then  cleanse  the  A'agina  and  external  genitals  thoroughly  with  bi- 


OPERATION   FOR    CHRONIC   ENDOMETRITIS 


647 


Fig.   560.      Scrubbing  the  Vagina. 


The  two  fingers  are  introduced  and  spread  apart,  as  shown  in  Fig.   561, 
so  as  to  smooth  out  all  folds. 


Fig.  561. 


Showing  how  the  fingers  are  separated  within  the  vagina.     Showing  also  the  long  strong  forceps 
holding  cotton  with  which  the  vaginal  walls  are  thoroughly  scrubbed. 


648 


DISEASES    OF    THE    UTEEUS 


chloride  solution  (1-2000),  -using  the  absorbent  cotton.  Then  introduce  the 
self-retaining  speculum  and  attach  to  it  a  bottle  containing  enough  water  to 
furnish  the  required  weight  (Fig.  562)  and  surround  the  operative  field  with 
towels  wrung  out  of  bichloride  solution  (1-2000)  or  with  towels  dry  sterilized 
or  with  the  sterile  ''perineal  sheet"  (Fig.  563).  The  bottle  used  for  a  weight  is 
not  sterile,  consequently  it  must  not  be  touched  directly  by  the  operator.  If 
it  is  necessary  for  it  to  be  hung  on  the  speculum  by  him,  he  must  grasp  it 
with  a  sterile  towel.  During  the  operation  it  is  entirely  covered  by  the  sterile 
sheet. 


Fig.  562.  Self-retaining  Speculum  introduced, 
and  weight  (bottle  with  water  in)  attached.  The 
amount  of  weight  may  be  varied  as  necessary  for 
different  patients  by  putting  more  or  less  water  in 
the  bottle. 


Fig.   563. 


Sterile    "perineal    sheet"    arranged    about 
the   field   of  operation. 


2.  Swab  out  the  vagina  again  with  tincture  of  iodine  followed  by  alco- 
hol (swabbing  out  also  the  cervical  canal  if  it  is  sufficiently  open),  catch  the 
cervix  with  the  tenaculum  forceps  and  dilate  it  with  the  small  dilator. 

The  canal  is  now  open  so  that  the  uterine  cavity  may  be  cleansed  with 
the  antiseptic  solution,  using  cotton  held  in  the  uterine  forceps.  Then  the 
large  dilator  is  introduced  and  the  cervix  is  thoroughly  dilated  (Figs.  563, 
564).     The  dilatation  should  be  carried  out  slowly  and  carefully,  the  direc- 


OPERATION   FOR    CHRONIC   ENDOMETRITIS 


649 


Fig.  564.     Introducing  the  Large  Dilator. 


Fig.  565.     The  Large  Dilator  in  Place.      (Gilliam — Practical   Gynecology.) 


650 


DISEASES    OF    THE    UTERUS 


tioii  of  tlie  dilatation  being  clianged  several  times,  to  secure  gradual  dilata- 
tion in  all  directions  and  prevent  rnptnre  of  cervix.  The  cervix  should,  in 
this  manner,  be  dilated  sufficiently  to  admit  the  large  curet  easily. 

In  certain  cases  in  which  the  cervix  is  abnormal,  it  may  suddenly  tear 
at  some  point  and  the  blade  of  the  dilator  will  pass  through  the  wall  of  the 
cervix  into  the  periuterine  connective  tissue.  To  prevent  this  accident  it  is 
well  to  keep  the  set-screw  at  the  handle  between  the  blades,  set  so  that  there 
can  be  no  sudden  wide  separation  of  the  dilating  portion  of  the  blades.  A 
dilatation  of  %  in.  to  I14  iii-  should  be  secured. 

3.  Cleanse  the  cavity  again  and  introduce  the  large  curet  (Fig.  566)  and 
clear  out  the  softened  endometrium.     The  curet  should  be  held  tightly  be- 


Fig.  566.     Introducing  the  Curet.     This  shows  the  form  of  the  curet  and  also  the  manner  of  steadying  the 

cervix  with  a  tenaculum  forceps. 


tween  the  thumb  and  the  fingers,  in  the  same  manner  as  a  pen  (Fig.  567). 
A  mark  on  the  handle  indicates  in  which  direction  the  cutting  edge  lies.  The 
interior  of  the  uterus  should  be  gone  over  systematically,  so  that  no  part  of 
the  surface  is  missed.  The  pressure  must  be  applied  carefully.  It  must  be 
firm  enough  to  remove  the  softened  diseased  tissue,  but  not  firm  enough  to 
remove  any  of  the  firm  tissue  beneath  it.  The  fact  that  comparatively  healthy 
firm  tissue  has  been  reached  is  indicated  by  the  grating  sensation  imparted  to 
the  curet.  As  a  rule  this  is  easilj^  recognized,  and  after  some  practice  the 
uterus  may  be  cleared  out  rapidly  and  safely.  In  exceptional  cases,  however, 
the  wall  of  the  uterus  is  diseased  to  a  considerable  extent  and  softened,  and 
care  is  necessary  to  avoid  penetration  of  the  wall. 


OPERATIOX   FOR    CHROXIC    ENDOMETRITIS 


651 


y      ^'^i«s3^fl9fliwi^s^ 


V 


Fig.  567.  Method  of  Holding  the  Curet.  It  should  be  held  like  a  pen,  so  that  every  gradation  of 
force  may  be  appreciated  and  regulated.  The  cutting  edge  of  the  curet  is  to  be  turned  in  every  direction 
and  the  shank  bent  sufficiently  to  systematically  curet  all  parts  of  the  cavity. 


Fig.  568.  Returning  the  Uterus  to  its  Normal  Position,  after  curetment,  and  making  the  Bimanual 
■Examination  under  Anesthesia.  The  Examination  under  Anesthesia  may  be  made  immediately  before  the 
•curetment  if  preferred. 


652 


DISEASES    OF    THE   UTERUS 


If  the  apparent  inflammation  has  been  of  long  standing,  the  scrapings 
should  be  saved  and  submitted  to  microscopic  examination,  that  malignant 
disease  or  tuberculosis  may  be  discovered,  if  present. 

After  the  surface  has  been  systematically  gone  over  with  the  sharp  curet, 
the  debris  is  removed  by  swabbing  with  cotton  in  a  forceps  or  by  irrigation 
if  preferred. 

4.  When  the  cavity  is  free  of  fragments,  it  is  packed  with  antiseptic 
gauze,  to  maintain  the  dilatation  of  the  cervix  for  forty-eight  hours.  If  there 
is  much  bleeding  it  may  be  diminished  by  one  or  two  applications  of  carbolic 
acid   (95%)   made  to  the  endometrium  before  the  packing.     If  the  carbolic 


Fig.  569.     Putting  in  the  Vaginal   Packing. 


application  is  made,  care  must  be  exercised  to  prevent  the  vagina  being  burned 
by  it. 

5.  After  the  uterine  cavity  has  been  packed,  cleanse  the  vagina,  intro- 
duce two  fingers  in  the  vagina,  remove  the  speculum  and  bring  the  fundus 
uteri  well  forward  by  bimanual  manipulation  (Fig.  568).  In  the  curetment, 
the  uterus  is  dra^vn  downward  somewhat  and  the  fundus  sometimes  goes 
backward.  Unless  the  uterus  is  brought  forward  into  normal  position  at  the 
close  of  the  operation,  it  is  likely  to  remain  in  retrodisplacement  and  cause 
trouble. 

If  it  is  desired  to  have  the  vaginal  and  intrauterine  packing  all  in  one 


OPERATION   FOR    CHRONIC    ENDOMETRITIS 

^^     ' ^ 


653 


Fig.  570.     The   Vaginal    Packing   in   Place,    and   the 
parts   cleansed. 


Fig.   571.     The    Sterile   Sheet  Removed,   and   the 
parts   ready   for  the   dressing. 


Fig.   572.     The    Vulvar    Dressing.      The    Gauze  Fig.   573.     The    Vulvar    Dressing.       The    Absorbent 

Applied.  Cotton    applied    over    the    gauze. 


654 


DISEASES   OF    THE   UTERUS 


piece,  so  that  it  can  be  more  easily  removed  later,  the  vaginal  portion  may 
be  held  in  the  palm  of  the  hand  (Fig.  569)  during  the  replacement  of  the 
uterus. 

At  the  same  time  that  the  fundus  uteri  is  being  brought  forward  (or  before 
beginning  the  curetment,  if  thought  preferable)  a  pelvic  examination  under 
anesthesia  may  be  made. 

In  many  of  these  cases  of  chronic  endometritis,  there  are  tubal  or  ovarian 
complications,  the  nature  and  extent  of  which  are  best  made  out  by  exami- 
nation under  anesthesia.  Again,  a  frequent  complication  of  chronic  endo- 
metritis is  adherent  retroversion,  and  it  is  important  to  determine  exactly  the 


\ 


:^' 


Fig.  574.     The  Vulvar  Dressing.     The  T-bandage  applied.      Notice  in   Figs.   573   and   574  that  the  dressing 
covers  the  entire  vicinity   of  the  operative  field,  including  the  pubes. 

environment  of  the  uterus — whether  it  can  be  brought  forward  without  danger, 
how  firm  and  extensive  the  adhesions  are  and  whether  there  is  any  collection 
of  pus  in  the  mass  of  adhesions  or  in  the  tubes. 

6.  "When  the  uterus  is  in  normal  position,  remove  the  tenaculum  forceps 
from  the  cervix,  spread  the  vagina  open  with  the  examining  fingers  and  pack 
the  vagina  lightly  with  gauze  (Fig.  569).  "When  this  vaginal  packing  is  fin- 
ished (Fig.  570),  remove  the  sterile  sheet  (Fig.  571)  and  put  on  the  dressing 
— first,  a  piece  of  gauze  (Fig.  572),  then  a  large  piece  of  absorbent  cotton  (Fig. 
573)  and  then  the  T-bandage  (Fig.  574). 


OPERATION   FOR    CHRONIC    ENDOMETRITIS 


655 


After  the  ciiretment,  in  chronic  endometritis  without  active  germs,  the 
interior  of  the  uterus  is  again  covered  with  epithelium  in  two  weeks  (Fig.  575), 
and  at  the  end  of  two  or  three  months  the  whole  endometrium  is  restored 
(Figs.  576  and  577).  This  new  endometrial  covering  is  supposed  to  come 
from  the  multiplication  of  the  epithelial  cells  lining  the  deeper  portions  of 
the  glands  which  are  not  removed  in  the  curetment. 

This  rapid  growth  of  a  new  (and  presumably  more  healthy)  endometrium 
after  curetment,  contrasts  markedly  with  the  results  following  cauterization 
of  the  endometrium  with  strong  cauterants,  such  as  nitric  acid  or  chloride 
of  zinc,  which  were  formerly  much  employed.  Fig.  578  shows  the  result  of 
such   destructive    caustic   action,    and   should   serve   as   a   sufficient   warning 


©-« 


Fig.   575.     Perpendicular    Section    of    the    Uterine    Mucous    Membrane,    Thirteen    Days    After    Curetment: 
a,  b,  epithelium,  newly-formed.      (Baldy — American  Textbook  of  Gynecology.) 


^:^ C 


Fig.  576.  Vertical  Section  of  the  Uterine  Mucous  Membrane,  Thirty-one  Days  after  Curetment: 
a,  a,  a,  cylindrical  epithelium;  b,  d,  proliferating  cells  in  the  deeper  part  of  the  epithelium;  c,  newly-formed 
stroma.     (Baldy — American  Textbook  of  Gynecology.) 


against  the  use  of  destructive  cauterants  within  the  uterus  before  the  meno- 
pause. 

After-care.  The  antiseptic  care  of  a  patient  after  curetment  is  practi- 
cally the  same  as  after  repair  of  cervix. 

The  vaginal  and  uterine  packing  is  removed  in  about  forty-eight  hours, 
and  an  antiseptic  vaginal  douche  (e.  g.,  1-5000  bichloride)  is  given  once  daily. 
The  vulvar  dressing  is  continued  for  ten  days.  The  patient  may  ordinarily 
get  up  in  three  or  four  days  after  curetment,  except  when  there  is  some  as- 
sociated disease  that  would  be  benefited  by  longer  rest  in  bed- — for  example, 
in  chronic  salpingitis  associated  with  chronic  endometritis,  the  patient  may  be 
kept  in  bed  ten  days  to  two  weeks  with  decided  benefit.     Some  hold  that  in- 


656 


DISEASES    OF    THE   UTERUS 


Fig.  577.  Vertical  Section  of  Uterine  Mucous  Membrane,  Three  Months  After  Curetment:  a,  epithe- 
lium; h,  newly-formed  glands;  c,  stroma  tissue;  d,  muscular  tissue  of  the  uterine  wall.  (Baldj' — Ameri- 
can Textbook  of  Gynecology.) 


in^^^^aEE^gg555£iFi33a^in^^3r - 


Fig.  578.  Vertical  Section  of  the  Uterine  Mucous  Membrane,  Fifty-three  Days  After  the  Applica- 
tion of  a  Caustic:  at,  epithelium;  b,  connective  tissue;  c,  c,  sections  of  glands  which  have  undergone  cystic 
degeneration;  d,  tubular  glands  enormously  dilated;  m,  muscular  tissue  of  the  uterine  wall.  (Baldy — 
American  Textbook  of  Gynecology.) 


SUBINVOLUTION    OF   UTERUS  657 

iiammatioii  in  the  tubes  or  other  tissues  about  the  uterus  is  a  contraindica- 
tion to  curetment,  but  the  writer  holds  just  the  opposite,  i.  e.,  that  chronic 
pelvic  inflammation  associated  with  chronic  endometritis  is  in  most  cases 
benefited  by  the  curetment. 

Curetment  is  only  one  step  in  the  treatment  of  chronic  endometritis.  The 
other  measures,  previously  mentioned,  should  be  carried  out  as  before,  until 
the  symptoms  subside.  Additional  intrauterine  applications  of  astringents,  the 
same  as  used  before  curetment,  may  be  necessary  in  exceptional  cases.  More 
benefit  may  be  expected  from  these  after  the  removal  of  the  bulk  of  the 
diseased  tissue  by  curetment  than  before.  It  is  well,  however,  not  to  disturb 
the  endometrium  for  at  least  one  month  after  the  curetment. 

Associated  pathologic  conditions,  such  as  malposition  of  uterus,  lacer- 
ation of  cervix,  laceration  of  pelvic  floor  and  pelvic  inflammation,  must  also 
be  corrected  as  far  as  possible,  for  if  alloAved  to  continue,  the  uterine  conges- 
tion resulting  therefrom  will  tend  to  prolong  the  endometritis  and  will  result 
in  the  reformation  of  a  thickened  bleeding  endometrium. 

SUBINVOLUTION  OF  UTERUS 

Subinvolution  is  the  term  applied  to  that  condition  of  the  uterus  found 
in  cases  in  which,  after  labor  or  abortion,  it  fails  to  return  to  its  normal  size. 
It  remains  large  and  heavy,  and  its  walls  have  not  the  usual  tone  and  firm- 
ness. 

Etiology 

Subinvolution  is  due  to  some  interference  with  the  retrograde  changes 
that  normally  follow  labor.  These  retrograde  changes  that  normally  take 
place,  consist  of  atrophy  of  the  muscular  and  connective  tissue.  Fatty  degen- 
eration, which  was  formerly  supposed  to  occupy  such  a  prominent  place  in 
the  process,  has  been  found  to  be  a  subordinate  feature.  The  retrograde 
changes  may  be  interfered  with  by  anything  that  prevents  proper  contrac- 
tion and  retraction  of  the  uterus  or  that  causes  chronic  congestion. 

A  uterus  which  becomes  infected  after  labor  does  not  return  to  its  nor- 
mal size  unless  the  infection  is  overcome. 

Retained  membranes  or  placental  remnants  also  interfere  with  the  process 
of  involution,  even  without  infection. 

General  diseases,  producing  an  impoverished  condition  of  the  blood  may, 
following  labor,  so  interfere  with  the  nutrition  of  the  uterus  as  to  cause  sub- 
involution. 

Retrodisplacement  of  the  uterus  after  labor  or  abortion,  is  another  cause 
of  subinvolution. 


658  DISEASES   OF    THE   UTERUS 

Pathology 

The  uterus  is  much  thickened,  both  the  muscular  wall  and  the  mucous  lin- 
ing being  involved.  Usually  both  the  body  and  the  cervix  are  affected, 
though  either  may  be  affected  alone.  The  muscular  fibers  remain  enlarged 
and  show  some  fatty  degeneration.  There  is  a  glandular  hypertrophy  in  the 
mucous  membrane  and  the  lymph  spaces  remain  enlarged.  The  enlarged 
uterus  often  tends  to  sink  low  in  the  pelvis  and  to  fall  into  retrodisplace- 
ment.  When  subinvolution  has  been  present  for  a  long  time,  more  or  less 
connective  tissue  hyperplasia  takes  place  and  the  change  becomes,  to  some 
extent,  a  permanent  one.  There  is  usually  emplanted  on  the  condition,  a 
simple  endometritis  of  the  hypertrophic  variety. 

Symptoms  and  Diagnosis 

The  symptoms  of  subinvolution  are  simply  a  sens©  of  weight  and  pres- 
sure and  weakness  in  the  pelvis,  with  menstrual  disturbances  (usually  in- 
creased flow) .  As  a  rule  the  most  prominent  symptoms  are  those  due  to  com- 
plications, such  as  hyperplastic  endometrium,  infected  endometritis  or  retrodis- 
placement. 

In  practically  all  cases  of  infection  following  labor  or  abortion,  there 
is  subinvolution,  but  as  the  endometrial  involvement  is  the  more  important 
lesion,  these  cases  usually  are  classed  as  endometritis.  The  term^  subinvolu- 
tion is  left  for  those  cases  in  which  the  enlargement  and  softening  of  the 
uterus  is  the  principal  lesion. 

The  enlarged  uterus  is  found  low  in  the  pelvis  and  not  particularly  ten- 
der, unless  there  is  a  complicating  endometritis.  The  uterus  may  be  retro- 
verted  and  there  is  often  laceration  of  the  pelvic  floor.  The  history  con- 
nects the  trouble  with  a  previous  labor  or  miscarriage. 

Treatment 

The  principal  disturbances  accompanying  subinvolution  come  from  the 
associated  diseases,  consequently  the  treatment  is  directed  largely  to  the 
associated  conditions.  The  following  measures  tend  to  tone  up  and  improve 
the  condition  of  the  uterine  wall  and  tend  also  to  benefit  the  accompanying 
endometritis. 

1.  Give  general  tonics  as  indicated  by  the  patient's  general  condition, 
and  uterine  astringents  (ergotin,  hydrastis,  stypticin)  to  tone  up  the  uterine 
wall. 

2.  Give  laxatives  as  indicated  by  the  condition  of  the  intestinal  tract. 

3.  Give  hot  vaginal  douches  (antiseptic  and  astringent),  for  example,  the 
bichloride  douche  or  the  alum  and  zinc  sulphate  douche. 

4.  Make  intrauterine  applications,  if  indicated  by  the  existing  endome- 


HYPERINVOLUTION    OF    UTERUS  659 

tritis.     Also,  employ  scarification  or  ichthyol-glycerine  tampons  or  vaginal 
suppositories  when  indicated. 

5.  Electricity  is  sometimes  of  benefit — vagino-abdominal  and  ntero-abdom- 
inal  applications  of  either  the  galvanic  current  or  faradic  current. 

6.  Curetment  is  the  most  effective  measure  for  checking  the  endometritis 
and  reducing  the  size  of  the  uterus.  Curetment  should  be  followed  by  the 
other  remedial  measures,  such  as  hot  douches,  laxative,  uterine  astringents 
internally  and,  if  necessary,  intrauterine  applications. 

7.  Repair  of  cervix  and  restoration  of  pelvic  floor  may  be  indicated. 
Where  the  cervix  has  been  severely  torn  or  there  is  severe  laceration  of  the 
pelvic  floor,  these  lesions  must,  of  course,  be  repaired. 

8.  Excision  of  cervix.  If  the  cervix  is  much  elongated,  th©  regular  wedge- 
shaped  amputation  may  be  carried  out  (Figs.  564,  566).  If  the  cervix  is  not 
large  enough  to  necessitate  that  and  yet  is  enlarged  and  heavy,  partial  ex- 
cision (Fig.  561)  may  be  carried  out. 

Prophylaxis  of  Subinvolution 

Subinvolution  is  one  of  those  diseases  which  may  in  a  measure  be  an- 
ticipated and  often  prevented.  The  measures  to  be  employed  in  the  puerperium 
to  avoid  subinvolution  are  as  follows : 

1.  Prevent  infection  following  labor  or  abortion  by  careful  attention 
to  asepsis. 

2.  See  that  the  uterus  is  emptied  of  placental  remnants  and  membranes. 

3.  Repair  all  lacerations  of  the  pelvic  floor. 

4.  Keep  the  uterus  "well  contracted.  If  it  shows  a  tendency  to  remain 
relaxed  during  the  puerperium,  give  strychnine  or  ergotin  or  both.  Hydras- 
tis tends  to  tone  up  the  uterus  and  keep  it  contracted.  Also  keep  the  bowels 
open  well,  to  relieve  pelvic  congestion,  and  maintain  the  patient  in  good  gen- 
eral condition  by  attention  to  the  general  health. 

5.  Prevent  retroversion  by  keeping  the  patient  on  the  side  after  the  first 
day  or  two,  and  not  much  on  the  back.  Before  discharging  the  patient,  make 
an  examination  and  determine  certainly  that  there  is  no  displacement. 

6.  If  there  is  a  generally  relaxed  condition  of  the  tissues  (uterus,  vag- 
inal walls,  etc.),  give  a  hot  vaginal  douche  (bichloride  1-5000)  twice  daily 
after  the  first  week  or  ten  days.  If  the  tissues  still  remain  relaxed,  then 
change  to  the  astringent  douche  of  alum  and  zinc  sulphate. 

HYPERINVOLUTION  OF  UTERUS 

Hyperinvolution  is  a  very  rare  condition  in  which  the  process  of  involu- 
tion following  labor  does  not  stop  at  the  normal  limit,  but  continues  until 
the  uterus  is  much  reduced  in  size.  The  uterus  sometimes  becomes  so  small 
as  to  measure  only  an  inch  in  depth.     The  cause  of  this  trouble  is  deficient 


660  DISEASES   OF    THE   UTERUS 

ovarian  function.  Obviously  the  condition  in  its  more  aggravated  form  is 
associated  with  amenorrhea.  While  formerly  this  amenorrhea  of  the  lacta- 
tion period  commonly  was  regarded  as  the  result  of  the  atrophic  condition 
of  the  uterus,  at  present  the  opinion  prevails  that  the  primary  underlying 
cause  is  to  be  found  in  a  deficiency  of  the  internal  secretory  function  of  the 
ovary.  The  process  of  ovulation  has  stopped  during  pregnancy.  After  la- 
bor, during  or  after  the  lactation  period,  ovulation  becomes  reestablished  as  soon 
as  the  general  condition  of  the  woman,  debilitated  by  pregnancy,  labor,  and  lac- 
tation, has  been  restored  to  its  normal  level.  During  the  period  of  cessation 
of  ovulation  no  corpora  lutea  are  formed.  Ovarian  hormones  fail  to  stimulate 
the  uterus.  The  result  of  this  lack  of  stimulation  is  amenorrhea  coincident 
with  atrophy  of  the  uterus.  If  the  ovulation  process  by  a  long-continued 
lactation,  especially  in  the  generally  weak  woman,  is  interrupted  for  an  un- 
duly extended  period,  and  the  uterus  thus  deprived  of  the  vegetative  ovarian 
hormone  for  a  very  long  time,  the  resulting  uterine  atrophy  may  become  per- 
manent. The  woman  has  entered  prematurely  into  her  menopause  (Ehren- 
fest,  American  Journal  of  Obstetrics,  1915).  The  principal  symptom  of  uterine 
hyperinvolution  is  painful  and  scanty  menstruation  or  amenorrhea.  The  treat- 
ment is  not  satisfactory.  The  same  treatment  is  employed  as  for  the  dysmenor- 
rhea and  scanty  menstruation  of  simple  atrophic  endometritis,  described  above. 
(See  Chapters  xiv  and  xv.) 

Recently  the  author  saw  a  most  interesting  case  of  hyperinvolution  of 
the  uterus  and  adnexa.  The  patient  was  thirty  years  of  age.  Three  years 
previously  she  had  had  a  severe  infection  following  the  birth  of  her  child, 
and  there  had  been  no  menstruation  since.  Pelvic  examination  showed  the 
uterus  to  be  very  small.  On  account  of  other  trouble  it  was  necessary  to 
open  the  abdomen,  and  thus  the  opportunity  was  given  of  inspecting  the  in- 
ternal genital  organs.  Everything  was  atrophic — the  uterus,  ovaries,  tubes, 
and  round  ligaments.     The  uterus  was  about  half  the  normal  size. 

SCLEROSIS  OF  THE  UTERUS 

Sclerosis  of  the  uterus  is  connective  tissue  hyperplasia  of  the  deeper  por- 
tions of  the  uterine  wall,  resulting  from  irritation  and  disturbance  of  nutri- 
tion as  manifested  in  the  various  forms  of  endometritis.  It  is  the  final  stage 
to  which  all  forms  of  uterine  inflammation  tend  and  which  they  finally  reach 
unless  checked.  It  is  eventually  the  substitution  of  scar-tissue  (new  connec- 
tive tissue)  for  the  parenchymatous  tissue-elements  (epithelial  cells  and  mus- 
cular fibers).  It  affects  the  entire  thickness  of  the  wall,  producing  a  strik- 
ing effect  both  in  the  mucous  membrane  and  in  the  muscular  tissue.  It  is 
known  also  as  chronic  interstitial  metritis,  areolar  hyperplasia,  cirrhosis  of 
-uterus  and  ''irritable  uterus."     When  located  principally  in  the  cervix,  the 


SCLEROSIS   OF    THE   UTERUS  661 

seat  of  laceration  and  chronic  inflammation,  it  is  known  as  inflammatory  hyper- 
trophy. 

Etiology 

It  is  due  to  persistent  chronic  inflammation  or  nutritive  disturbance  within 
the  uterus. 

It  is  favored  by  chronic  inflammation  around  the  uterus  or  by  pelvic 
tumors  that  cause  persistent  uterine  congestion.  It  is  predisposed  to  by  dis- 
eases that  depress  the  general  health  and  nutrition,  especially  by  the  blood 
conditions  associated  with  cirrhosis  of  the  kidney  and  arteriosclerosis.  It  is 
usually  due  to  one  of  the  following  chronic  affections: 

Laceration  of  cervix,  with  resulting  chronic  inflammation. 

Ulcer  of  cervix,  with  deep  inflammation. 

Chronic  endocervicitis,  with  cystic  degeneration. 

Chronic   infected   endometritis. 

Chronic  simple  endometritis. 

Subinvolution. 

It  may  follow  destructive  cauterization  of  the  endometrium,  for  example, 
with  zinc  chloride  or  with  steam. 


Pathology 

The  essential  changes,  are  hyperplasia  of  the  connective  tissue  and  loss  of 
the  parenchymatous,  elements  (epithelial  cells  and  muscle  fibers).  Following 
the  inflammatory  affections,  the  connective  tissue  hyperplasia  is  more  active, 
crowding  the  special  cells  and  causing  them  to  atrophy  and  finally  disappear. 
Following  the  purely  iiutritive  disturbances  (subinvolution,  simple  endome- 
tritis) the  parenchymatous  atrophy  rather  precedes  the  connective  tissue  pro- 
liferation, the  latter-  being  secondary  and  to  some  extent  reparative.  The 
process  of  sclerosis  affects  not  only  the  endometrium  but  also  the  myometrium, 
so  that  practically  the  whole  wall  of  the  uterus  is  involved.  Figs.  579  and  580 
very  clearly  show  the  contrast  between  the  normal  and  fibrotic  uterine  wall. 

When  the  process  follows  subinvolution,  the  uterus  remains  much  en- 
larged for  a  long  time.  At  this  stage  the  tissues  are  rather  soft  and  the 
whole  uterus  may  feel  flabby  and  atonic.  Later,  however,  the  new  connective 
tissue  shrinks  and  the  uterus  becomes  firm  and  rigid  and  smaller.  If  the 
uterus  was  much  enlarged  as  from  subinvolution,  it  would  hardly  be  reduced 
to  normal  size  by  this  shrinking.  But  in  a  uterus  only  slightly  enlarged,  as 
from  chronic  inflammation,  it  May  be  reduced  to  normal  size  or  even  smaller. 
In  certain  cases,  this  hyperplasia  may  progress  to:  considerable  extent  in  the? 
myometrium  before  involving  the  endometrium,  for  example^  following:  sub- 
involution. Here  the  whole  muscular  wall  may  show  marked  .^.glerosis  (con- 
nective tissue  hyperplasia   and  muscular   atrophy)    while  the  endometrium 


662 


DISEASES    OF    THE   UTERUS 


shows  only  simple  hypertrophic  endometritis    (hypertrophy  of  stroma  cells 
and  glands).    Later  the  endometrium  also  undergoes  the  sclerotic  changes. 

Symptoms  and  Diagnosis 

The  symptoms  and  signs  of  sclerosis  or  chronic  interstitial  metritis  are 
those  of  the  chronic  endometritis,  with  the  following  exceptions : 


/f 


Fig.   579.     Diffuse  Fibrosis  of  the  Uterus,  due  usually  Fig.  580.     Normal    Uterine    Wall.      Shown    here 

to  subinvolution  and  chronic  metritis.  to   contrast   with  the   thickened   wall.     The   two   are 

magnified  equally. 

1.  In  those  cases  in  which  the  sclerosis  has  progressed  so  far  that  the 
endometrium  is  involved,  the  menstrual  flow  is  scanty  instead  of  profuse, 
and  in  some  cases  it  is  absent. 

2.  The  discharge  is  not  so  profuse  as  is  usually  present  in  endometritis 
that  produces  as  much  distress. 


SCLEROSIS    OF    THE   UTERUS 


663 


3.  The  general  disturbance  and  reflex  symptoms  and  local  distress  are 
usually  more  marked  and  more  rebellious  to  treatment  than  is  endometritis. 
The  fact  that  there  is  more  general  disturbance  with  this  affection  may  be 
due  partly  to  the  debilitating  disease  that  preceded  and  led  up  to  the  sclerosis. 

4.  When  the  process  is  well  marked,  the  enlarged  uterus  is  firmer  in  con- 
sistency than  the  normal  uterus  or  than  a  uterus  which  is  the  seat  of  endo- 
metritis only. 

5.  Usually  in  sclerosis,  the  uterus  is  more  sensitive  than  in  chronic  en- 
dometritis.   Bimanual  examination  and  sounding  cause  more  pain. 

6.  In  the  cervix  the  enlargement  may  be  directly  seen. 


^ 


lA. 


'•^tte^^ 


"s 


Fig.  581.     Tuberculosis  of  the  Endometrium.     Two  large  giant  cells  are  clearly  seen,  each  lying  in  a 

marked  tubercle. 


well- 


V  Treatment 

Sclerosis  is  little  amenable  to  treatment  when  it  is  well  established, 
but  it  may  to  a  large  extent  be  prevented,  and  consequently  preventative  treat- 
ment is  very  important.  This  consists  in  checking,  so  far  as  possible,  all 
chronic  inflammatory  and  nutritive  disturbances  in  the  uterus,  correcting 
displacements  and  restoring  the  normal  condition.  No  treatment  can  remove 
the  excess  of  connective  tissue  and  restore  the  normal  fibers.  Treatment, 
however,  may  do  good  in  two  ways — (1)  by  removing  endometritis  and  dis- 
placement and  laceration,  and  thus  removing  many  of  the  troublesome  asso- 
ciated symptoms,  and  (2)  by  checking  the  further  progress  of  the  sclerosis 
or  at  least  diminishing  the  rapidity  of  such  progress. 

1.  Endometritis,  displacements,  lacerations  and  other  affections  present, 
should  be  treated  as  described  elsewhere.    In  sclerosis  of  the  cervix  (inflam- 


664  DISEASES    OF    THE   UTEKUS 

matory  hypertrophy)  a  considerable  portion  of  the  redundant  tissue  may  be 
removed  in  denudation  for  repair,-  and  the  chronic  irritation  which  is  aug- 
menting the  sclerosis  is  at  the  same  time  removed. 

"When  sclerosis  takes  place  without  laceration  (simply  from  endocervicitis 
or  a  nutritive  disturbance),  a  portion  of  the  cervix  may  be  removed  by  excision 
of  a  wedge  of  tissue  on  each  side,  making  a  wound  resembling  a  deep  bilateral 
tear.  In  some  cases,  both  lacerated  and  non-lacerated,  it  is  advisable  to  do  a 
regular  amputation  of  the  cervix,  though  such  excessive  enlargement  in  scle- 
rosis is  rare. 

2.  Eemoval  of  the  accompanying  disturbance  has  much  to  do  with  check- 
ing the  spread  of  the  disease. 

An  additional  step  in  this  direction  is  the  building  up  of  the  patient's  gen- 
eral health  in  every  possible  way  and  the  removal  of  all  causes  of  pelvic  con- 
gestion. 

With  a  view  to  causing  absorption  of  the  redundant  tissue,  various  altera- 
tives have  been  administered,  particularly  mercury  and  iodine  in  different 
forms,  but  without  any  decided  effect.  As  local  measures,  the  following  may  be 
used :  hot  douches,  glycerine  tampons,  and  ichthyol  to  cervix  and  as  an  intra- 
uterine application.  Skene  considered  electricity  more  useful  than  any  other 
remedy  in  this  affection.  It  may  be  tried  by  the  various  methods  mentioned 
in  Chapter  iii.  After  the  menopause,  the  symptoms  may  disappear,  though 
this  is  by  no  means  certain  to  occur. 

TUBERCULOSIS  OF  THE  UTERUS 

This  term  is  applied  to  tubercular  disease  of  the  uterine  mucosa  and  myo- 
metrium. When  the  tuberculosis  affects  only  the  peritoneal  coat  of  the  uterus 
it  is  classed  as  peritoneal  tuberculosis. 

Etiology 

Tuberculosis  of  the  uterus  usually  comes  from  tuberculosis  of  the  tubes. 
Occasionally  it  is  due  to  infection  from  without,  in  which  case  it  may  come 
|rom  tuberculosis  of  the  external  genitals. 

It  may  be  produced  by  coitus  with  a  tubercular  husband,  the  tuberculosis 
in  the  husband  being  ].oeated  in  the  genito-urinary  tract.  It  is  possible  for 
the  infection  to  bC;  carried  in  this  way  when  the  husband  has  only  pulmonary 
tuberculosis,  for  tubercular,  bacilli  have  been  demonstrated  in  the  compara- 
tively healthy  testes,  and  semen  ,of  phthisicaL  patients.  Infection  conveyed,  by 
coitus  may  be  first  manifested  in  the  cervix  or  in  the  body  of  the  uterus;  j  It 
is  held  by  some  that  such  infection  may  be  first  foruid  in  the  Fallopian  tubes. 
TuUefculosis  of  the  uterus  sometimes  occurs  as  a  part  of  a  general  infection, 
secondary  to  .pulmonary  tuberculosis.  ,  ,     .-      , 


TUBERCULOSIS  OF  THE  UTERUS  665 

Pathology 

Tuberculosis  of  the  corpus  uteri  is  usually  associated  with  tubeireulosis 
of  the  Fallopian  tubes.  Like  other  forms  of  genital  tuberculosis,  it  occurs 
almost  exclusively  in  patients  with  pulmonary  or  intestinal  tuberculosis. 

It  affects  principally  the  endometrium  and  usually  does  not  extend  to  the 
muscular  portion  of  the  wall  until  late  (Fig.  581).  It  may  appear  as  (a) 
miliary  tuberculosis,  (b)  diffuse  ulcerating  tuberculosis  (caseous  form)  or 
(c)  fibroid  tuberculosis — each  form  presenting  practically  the  same  distin- 
guishing characteristics  here  as  elsewhere. 

Tuberculosis  of  the  cervix  is  very  rare  and  is  usually  associated  with  tuber- 
culosis of  the  vagina.  It  appears  in  the  form  of  a  chronic  ulcer,  which  resists 
treatment. 

Symptoms  and  Diagnosis 

The  symptoms  of  tuberculosis  of  the  endometrium  are  principally  those 
of  a  severe  chronic  infected  endometritis.  There  is  nothing  particularly  dis- 
tinctive in  the  clinical  evidences  of  tubercular  endometritis.  A  severe  endo- 
metritis occuring  in  a  virgin  should  arouse  suspicion  of  tuberculosis.  A  per- 
sistent and  severe  chronic  endometritis  in  the  presence  of  peritoneal  or  tubal 
tuberculosis  or  occurring  in  a  patient  with  phthisis,  is  possibly  tubercular. 
The  diagnosis  is  made  by  finding  tubercle  bacilli  in  the  pus  or  finding  charac- 
teristic changes  in  the  scrapings  from  the  uterus. 

Treatment 

In  all  cases,  give  general  antitubercular  treatment.  Tuberculosis  of  the 
lower  part  of  the  cervix  alone,  calls  for  amputation  of  the  cervix  or  hysterec- 
tomy. Tuberculosis  of  the  body  of  the  uterus  indicates  hysterectbmy  (usually 
vaginal),  provided  there  is  no  other  involvement,  e.g.,  advanced  phthisis  or 
very  extensive  peritoneal  involvement.  A  moderate  involvement  of  tubes  and 
pelvic  peritoneum  is  not  a  contraindication  to  operation,  provided  the  patient 
is  in  a  fair  general  condition.  In  cases  in  which  the  patient  is  not  in  fit  con- 
dition for  radical  operation,  or  refuses  the  same,  the  case  is  treated  on  the 
same  general  principles  as  chronic  infected  endometritis,  that  is,  by  curet- 
ment  followed,  if  necessary,  by  antiseptic  and  astringent  applications.  Iodo- 
form should  be  used  freely,  in  powder  or  emulsion  or  as  soluble  bougies. 
While  a  cure  may,  in  some  cases,  follow  this  mild  treatment,  its  attainment  is 
very  uncertain,  and  owing  to  the  impossibility  of  determining  the  limit  of  the 
uterine  infiltration  and  Owiiig  also  to  the  fact  that  the  inffltfation  is  very  likely 
to  spread  in  spite  of  all  treatment,  hysterectomy  is  the  safei  plan  and  the  one 
to  be^advised.  •  '  -  ..;     •  '     :    •       ^  •  ./■' 


666  DISEASES    OF    THE    UTERUS 

SYPHILIS  OF  THE  UTERUS 

111  a  most  exhaustive  monogTaph.  G-ellliorn  and  Ehreiifest  (American 
Journal  of  Obstetrics,  1916)  have  presented  tlie  entire  problem  of  tbe  involve- 
ment of  the  internal  female  genitals  by  syphilitic  infection. 

The  cervix  comparatively  often  is  the  seat  of  a  primaiy  chancre.  Sec- 
ondary manifestations  in  form  of  macules  and  papules  may  be  found  on  the 
surface  of  the  cervix.  Of  an  eminently  practical  importance  is  the  develop- 
ment of  a  tertiary  gummatous  gro^vth  in  the  cervix.  While  at  first  of  a  firm 
consistence,  it  usually  breaks  dovm  as  the  result  of  necrotic  changes.  An  ir- 
regular-shaped deep  ulcer  surrounded  by  hard  infiltrated  tissue  forms,  which, 
as  shown  by  these  writers,  often  has  been  mistaken  for  cervical  carcinoma. 

Our  actual  knowledge  concerning  the  syphilitic  lesions  of  the  uterine 
body  is  extremely  meager.  Primary  and  secondary  manifestations  have  not 
been  observed  in  the  uterus.  There  are  a  few  instances  of  gumma  in  the 
uterine  wall  on  record,  also  of  a  gummatous  endometritis.  This  infrequency 
of  tertiary  lesions  is  rather  a  matter  of  surprise,  for  the  uterus  more  than  any 
other  internal  organ  of  the  body  is  exposed  to  direct  infection.  Spirochetes 
may  reach  the  endometrium  from  the  vagina  or  from  cer^'ical  lesions.  Spiro- 
chetes, at  least  during  pregnancy,  undeniably  circulate  through  the  uterine 
wall  as  is  proved  by  the  fact  that  an  actively  syphilitic  mother  invariably  in- 
fects the  fetus  in  the  uterus.  The  iuA'estigations  of  Gellhorn  and  Ehrenfest 
tend  to  show  that  it  is  not  justifiable  to  speak,  as  various  writers  are  doing,  of 
a  tj-pical  syphilitic  metrorrhagia  presumably  caused  by  definite  pathologic 
changes  in  the  myometrium. 

Syphilis  is  a  common  cause  of  abortion.  It  is  this  frequency  of  abor- 
tions in  luetic  women  and  the  notorious  complication  of  a  luetic  with  a  gonor- 
rheal infection  in  the  same  individual  which  account  for  the  established  fact 
that  women  with  a  strongly  positive  Wassermann  reaction  so  often  exhibit 
metrorrhagia  as  a  predominant  symptom.  The  diagnosis  of  a  syphilitic  af- 
fection of  the  cervix  is  made  from  the  more  or  less  characteristic  appearance 
of  the  lesion  in  an  evidently  syphilitic  woman  with  a  positive  Wassermann 
reaction  and  is  rendered  positive  by  the  finding  of  spirochetes  in  a  smear 
made  from  the  serous  exudates  covering  the  lesion.  In  suspicious  looking 
ulcers  the  microscopic  study  of  an  excised  piece  of  tissue  becomes  indis- 
pensable. A  wrong  diagnosis  of  carcinoma  may  prove  disastrous  to  the 
patient. 

Luetic  affections  heal  very  readily,  especially  under  specific  general 
treatment,  the  only  treatment  actually  required  in  these  cases. 

ECHINOCOCCUS  DISEASE  OF  UTERUS 

This  disease  affecting  the  uterus  is  a  curiosity,  and  yet  it  is  not  so  rare 
that  it  can  be  ignored  in  diagnosis.    Undoubted  cases  have  been  reported  in 


ECHINOCOCCUS   DISEASE   OF   UTERUS  667 

■early  life  and  in  middle  life  ^id  later.  The  liver  is  the  organ  usually  af- 
fected in  echinococcus  disease.  Many  other  organs,  however,  have  been  af- 
fected, with  or  without  coincident  affection  of  the  liver,  and  among  the  or- 
gans occasionally  affected  is  the  uterus. 

When  echinococcus  disease  attacks  the  uterus,  there  is  nothing  especially 
characteristic.  The  disease,  at  first,  may  resemble  chronic  endometritis  with 
bemorrhagic  tendency.  As  the  cysts  becomes  larger,  a  tumor  or  several 
tumors  become  palpable,  and  the  case  may  be  considered  one  of  uterine 
fibroids.  When  the  masses  become  still  larger,  fluctuation  may  be  detected 
or  rupture  into  the  uterine  cavity  may  take  place  with  the  discharge  of  clear 
fluid  and  booklets,  and  daughter  cysts.  If  rupture  takes  place  into  the  peri- 
toneal cavity,  fatal  peritonitis  is  probable.  The  process  may  stop  at  any  stage 
and  the  lesion  undergo  partial  absorption.  Suppuration  may  take  place  in 
the  lesion,  forming  abscesses.  In  some  cases  the  symptoms  resemble  preg- 
nancy, as  mentioned  by  Keed,  as  follows : 

*'In  cases  of  echinococcus  infection  of  the  uterine  cavity,  the  symptoms 
may  be  essentially  those  of  pregnancy.  The  uterus  becomes  enlarged  and 
softened,  the  cervix  presenting  a  bluish  aspect.  The  womb  enlarges,  progres- 
sively and  symmetrically,  the  breasts  enlarge  and  may  contain  milk,  while 
there  are,  not  infrequently,  reflex  disturbances  of  the  stomach.  It  is  the  occur- 
rence of  these  symptoms  which  has  generally  caused  infections  of  the  uterine 
cavity  by  echinococcus  to  be  looked  upon  as  pregnancy,  and  the  resulting  cysts 
to  be  designated  as  degenerated  ova.  In  practically  all  these  cases,  however, 
the  usual  amenorrhea  of  pregnancy  is  absent,  while  the  patient  complains  of 
more  or  less  constant  dribbling  of  blood  from  the  uterus.  While  this  is  true, 
the  fact  must  be  recognized  that  infection  of  the  uterine  cavity  may  coexist 
with  pregnancy,  as  was  true  in  MacNeven's  case,  in  which  a  large  echinococ- 
<^.us  cyst  was  expelled  intact,  during  a  true  labor  and  immediately  preceding 
the  rupture  of  the  amniotic  sac.  The  exact  diagnosis  can  not  be  made  without 
the  demonstration  of  the  booklets." 

Echinococcus  disease  of  the  uterus  must  not  be  confounded  with  the  more 
common  "hydatid  mole,"  in  which  small  cysts  of  varying  size  are  found, 
and  may  be  expelled  in  a  large  mass.  The  two  affections  are  entirely  dis- 
tinct. The  first  (echinococcus  disease)  is  due  only  to  the  echinococcus  para- 
site in  the  uterus,  while  the  second  (hydatid  mole)  is  due  to  degenerative 
changes  in  fetal  membranes — the  chorionic  villi  proliferating  and  becoming 
distended  with  fluid  so  as  to  form  a  mass  of  little  cysts.  This  affection  (hy- 
datid mole)  is  rather  frequent  and  is  described  in  obstetric  works.  Occasion- 
ally the  degenerating  chorionic  villi  take  on  malignant  characteristics  and  give 
rise  to  that  form  of  uterine  tumor  known  as  chorioepithelioma. 

The  differential  diagnosis  between  echinococcus  disease  and  hydatid  mole 
is  made  by  microscopic  examination  of  the  pathologic  structures — booklets 
being  found  in  the  first  and  chorionic  villi  in  the  second. 


668  DISEASES   OP    THE   UTERUS 

The  treatment  of  ecMiio coccus  disease  of  the  uterus  consists  in  the  rup- 
ture and  continual  drainage  of  all  cyst  cavities,  combined  with  the  use  of  the 
antiseptics  and  astringents  recommended  for  endometritis.  If  the  disease 
persists  and  is  not  associated  with  some  contraindicating  lesion,  hysterectomy- 
is  indicated. 


CHAPTER  VII 


DISPLACEMENT  OF  THE  UTERUS 


POINTS  IN  ANATOMY 

The  uterus  is  situated  about  the  center  of  the  pelvic  cavity  (Figs.  582,  583) 
with  the  body  of  the  organ  inclined  forward,  the  long  axis  of  the  organ  being 
directed  to  a  point  above  the  symphysis  pubis,  the  direction  varying  in  different 
individuals  and  in  the  same  individual  at  different  times.    The  uterus  is  not  fixed 


Fig.  582.     Section  of  a  Frozen  Body,  showing  the  usual  Position  of  the  Uterus.      (Sellheim — 

Weihliches  Becken.) 

in  one  position,  but  can  be  moved  easily  in  all  directions — upward,  downward, 
forward,  or  laterally.  It  is  pressed  somcAvhat  backward  in  the  pelvis  Avhen  the 
bladder  is  distended  (Fig.  324)  and  somewhat  forward  when  the  upper  part  of 
the  rectum  is  distended. 

It  is  seen,  therefore,  that  the  uterus  possesses  normally  a  considerable 

669 


670 


DISPLACEMENT   OF    THE   UTERUS 


range  of  mobility,  and  it  is  only  when  it  is  found  beyond  the  normal  range 
that  it  can  be  said  to  be  displaced. 

What  Holds  the  Uterus  in  Normal  Position?  As  just  stated,  there  i& 
nothing  that  holds  the  uterus  immovably  in  any  one  position.  By  a  combi- 
nation of  several  factors  it  is  prevented,  ordinarily,  from  going  beyond 
certain  limits,  and  is  permitted  free  mobility  within  those  limits. 

The  factors  that  thus  assist  in  maintaining  the  uterus  within  normal  limits, 
or  rather  assist  in  preventing  its  remaining  permanently  beyond  the  normal 
limits,  are  the  following: 


\ 


Fig.  583. — A  View  from  in  front,  showing  the  usual  Position  of  the  Uterus.     This  is  the  same  frozen  body- 
shown  in   Fig.    582.      (Sellheim — W eihliches  Becken.) 


The  pelvic  floor  (see  Chapter  v) . 
The  sacro-uterine  ligaments  (see  Chapter  vi). 
The  broad  ligaments  (see  Chapter  vi). 
The  round  ligaments  (see  Chapter  vi). 
The  normal  weight  and  size  of  the  uterus. 
The  normal  tone  and  fullness  of  the  pelvic  tissues. 
A  large  heavy  uterus  tends  to  downward  displacement  and  backward  dis- 


BETRODISPLACEMENT   OF    THE   UTERUS  671 

placement  more  than  one  of  normal  size.  After  the  menopause  the  atrophy 
of  muscular  tissue  and  absorption  of  fat  may  so  interfere  with  the  normal  tone 
and  fullness  of  the  tissues  as  to  be  a  factor  in  prolapse  of  the  uterus.  The 
previous  laceration  of  the  pelvic  floor  in  these  cases  was  not  sufficient  in 
itself  to  cause  the  prolapse. 

BACKWARD  DISPLACEMENT  OF  THE  UTERUS 

Backward  displacement  of  the  uterus  occurs  in  two  forms — retroversion 
and  retroflexion.  In  retroversion,  the  uterus  as  a  whole  is  turned  backward, 
the  relation  between  the  cervix  and  the  body  remaining  the  same.  In  retro- 
flexion, the  upper  part  of  the  uterus  is  hent  backward,  the  point  of  bending 
being  about  at  the  internal  os.  The  cervix  may  retain  its  normal  position  in  the 
pelvis  but  its  relation  to  the  fundus  uteri  is,  of  course,  much  changed. 

In  nearly  all  cases  of  backward  displacement  of  the  uterus,  there  is  both 
a  retroversion  and  a  retroflexion.  The  causes  of  these  two  displacements  are 
about  the  same,  the  symptoms  are  much  the  same,  the  treatment  is  practically 
the  same  and,  as  the  two  conditions  are  nearly  always  associated,  they  should 
be  considered  together.  ''Retrodisplacement"  is  the  term  the  author  shall 
generally  use  in  referring  to  a  backward  displacement  of  the  uterus.  It 
includes  retroversion  and  retroflexion  and  the  combination  of  the  two. 

Etiology 

A  consideration  of  the  factors  concerned  in  maintaining  the  uterus 
within  the  limits  of  normal  position,  will  indicate  in  a  measure  the  causes  of 
displacement.  It  is  seldom,  however,  that  one  factor  alone  is  affected,  but 
usually  several.  There  are  various  ways  of  classifying  the  causes  of  retro- 
displacement  of  the  uterus.  The  author  finds  the  following  classification  satis- 
factory and  convenient  in  actual  Avork: 
A.  Causes  Connected  With  Labor  or  Miscarriage. 

1.  Injury  of  the  Pelvic  Floor  and  accompanying  relaxation  of  other  sup- 

porting structures. 

a.  Pelvic    floor — laceration    unrepaired,    overstretching    or    sub- 

sequent subinvolution. 

b.  Sacro-uterine  ligaments — overstretching  or  subinvolution. 

c.  Broad  ligaments,  round  ligaments  and  other  pelvic  tissues — 

overstretching  or  subinvolution. 

d.  Vaginal  wall — overstretching  or  subinvolution,  producing  sub- 

sequent dragging  on  cervix. 

2.  Subinvolution  of  Uterus  following  labor  or  miscarriage — 

a.  Of  corpus,  due  to  infection  or  to  placental  remnants  or  blood  clots 
retained,  or  to  an  atonic  condition  of  uterus  from  other  cause 
(anemia,  poor  pelvic  circulation). 


672  DISPLACEMENT    OF    THE   UTERUS 

b.  Of  cervix,  due  to  laceration  witli  infection  of  cervical  tissue,  or 
to  persistent  relaxation  or  atonic  condition  from  other  cause. 

3.  Scars  in  upper  part  of  vagina,  drawing  cervix  forward. 

4.  Getting  up  too  soon  after  labor  or  at  work  too  soon  (displacement  is 

favored  by  the  heavy  uterus  and  the  relaxed  vaginal  wall  and  pelvic 
floor). 

5.  Constant  dorsal  position  after  labor  or  miscarriage. 

B.  Non-puerperal  Changes  in  Uterus. 

1.  In  the  cervix  uteri. 

a.  Inflammatory  hyj^ertrophy. 

b.  Idiopathic  hypertrophy. 

c.  Tumors. 

d.  Undue  dragging  down,  in  examinations  and  operations. 

2.  In  the  corpus  uteri. 

a.  Inflammation — increasing   the    weight   of   the   uterus   so    that   it 

drags  on  its  supports.  Also,  in  some  cases,  by  causing  soften- 
ing and  lack  of  tone  in  the  walls  so  that  the  organ  bends 
backward  more  easily  on  occasion,  and  does  not  possess  the 
tonic  elasticity  to  return  to  its  former  shape. 

b.  Tumors  in  the  anterior  wall  or  the  posterior  wall  or  in  the  in- 

terior of  the  uterus.    And  also  projecting  polypi. 

c.  Senile  atrophy. 

d.  Displacement  and  failure  to  replace,  in  examination  or  operation. 

C.  Non-puerperal  Changes  in  the  Supporting  Structures. 

1.  Eelaxation  and  stretching  from  certain  kinds   of  work. 

2.  Relaxation  and  stretching  from  faulty   dress. 

3.  Relaxation  and  stretching  from  full  bladder  (pushing  fundus  back), 

or  full  rectum  (pushing  cervix  forward). 

4.  Stretching  by   conditions  that  increase   the  intraabdominal  pressure 

(persistent  cough,  straining  efforts  from  stricture  of  rectum  or  from 
chronic   bladder  disease,   etc.). 

5.  Relaxation  from  general  atonic  conditions   (anemia,   etc.).       This  is 

often  accompanied  by  general  j)oor  support  of  the  abdominal  organs 
(splanchnoptosis  or  enteroptosis),  due  to  repeated  pregnancies  with 
poor  recuperation  afterward  or  to  other  cause. 

6.  Stretching  in  examinations  and  operations. 

7.  Absorption  of  muscle  and  fat  in  pelvis,  due  to  wasting  disease  or  to 

senility.  This  is  one  of  the  important  factors  in  prolapse  and  retro- 
displacements  that  come  on  after  the  menopause. 

D.  Pelvic  Tumors. 

1.  Ovarian  and  Broad  Ligament  tumors. 

2.  Other  Tumors  arising  in  the  pelvis  or  extending  into  the  pelvis. 


RETKODISPLACEMENT   OF    THE   UTERUS  673 

E.  Pelvic  Inflammation. 

1.  Cellulitis  in  front  of  uterus  with  the  formation  of  contracting  tissue, 

drawing  cervix  forward. 

2.  Peritonitis,  principally  perisalpingitis  and  perioophoritis  forming  ad- 

hesions with  the  intestines  and  the  pelvic  wall,  which  adhesions 
contract  later  and  tend  to  drag  the  fundus  uteri  backward. 

3.  Chronic  oophoritis   (follicular),  increasing  the  weight   of  the   ovary, 

and  prolapse  of  ovary,  tending  to  drag  the  uterus  backward.  Also 
chronic  salpingitis  may  cause  thickening  of  the  tubes  and  prolapse 
backward  and  draggmg  on  fundus  uteri. 

F.  Developmental  Defects  (congenital  causes),  often  the  expression  of  general 

infantilism  (Chapter  xv). 

1.  Short  Vagina,  holding  cervix  too  far  forward. 

2.  Long  Cervix  held  forward  by  the  pelvic  floor,  so  that  the  body  of  uterus 

must  be  either  in  backward  displacement  or  be  sharply  flexed  for- 
ward on  the  cervix. 

3.  Imperfect  Descent  of  Ovary,  causing  the  upper  posterior  part  of  the 

broad  ligament  to  draw  backward. 

G.  Falls. 

Pathology 

The  essential  pathologic  change  is  indicated  in  the  name  and  in  the  defi- 
nition. The  amount  of  backward  displacement  may  be  very  conveniently 
expressed  as  first  or  second  or  third  degree.  In  retrodisplacement  of  the 
first  degree,  the  fundus  lies  just  about  at  the  promontory  of  the  sacrum,  in 
the  second  degree  the  fundus  lies  in  the  hollow  of  the  sacrum,  while  in  the 
third  degree  it  lies  well  down  in  the  cul-de-sac  below  the  level  of  the  internal 
OS  (Fig.  323).  Of  course  in  practice  all  gradations  are  found,  from  the  normal 
position  to  the  most  marked  backward  displacement.  The  exact  dividing  line 
between  the  different  degrees  is  not  distinct  and  the  division  into  first  and 
second  and  third  degrees  is  an  artificial  one  but  very  convenient,  and  usually 
cases  on  examination  may  be  easily  placed  in  one  class  or  the  other  and  so 
recorded. 

The  association  of  version  and  flexion  is  alm.ost  constant,  a  pure  retro- 
version or  a  pure  retroflexion  being  rare.  The  most  common  lesion  is  that 
shown  in  Fig.  67 — the  uterus  is  turned  backward  far  enough  for  the  cervix 
to  point  forward  and  then  it  is  flexed  still  further.  The  cervix  is  found  point- 
ing more  or  less  towards  the  vaginal  orifice,  the  body  of  the  uterus  is  absent 
ia  front  and  is  found  posteriorly,  at  the  promontory  or  in  the  hollow  of  the 
sacrum  or  low  in  the  cul-de-sac,  as  in  Fig.  67. 

The  broad  ligaments  are  twisted  more  or  less  and  the  return  circulation 
through  them  is  impeded.  This  causes  chronic  congestion  of  the  uterus,  en- 
gorgement, cellular  infiltration,  simple  endometritis  and  hypertrophy. 

If  the  displacement  follows  labor  or  abortion,  it  interferes  with  the  nor- 


67-1  DISPLACE^IEXT    OF    THE    UTERUS 

mal  process  of  involution  and  causes  subinvolution.  If  it  is  accompanied 
with  infection,  it  aggravates  the  resulting  inflammation. 

If  it  occurs  -with  laceration  of  the  pelvic  floor  (and  the  association  is  very- 
common),  it  increases  the  distress  of  that  condition  and  tends  to  cause  pro- 
lapse, by  increase  in  the  Aveight  of  the  uterus  and  also  by  bringing  the  point 
of  the  uterine  wedge  (instead  of  a  broad  surface)  to  press  against  the  weak 
place  in  the  pelvic  floor  (Fig.  268). 

The  fundus  as  it  goes  back  in  the  pelvis  frequently  takes  the  tube  and 
ovary  of  one  or  both,  sides  with  it  to  some  extent.  The  ovaries  are  the  struc- 
tures the  more  frequently  displaced,  and  one  or  both  of  them  may  be  found  in 
the  hollow  of  the  sacrum  close  to  the  displaced  fundus,  or  even  below  it  in 
the  cul-de-sae.  This  irritation  of  the  ovaries  may  result  in  their  functional 
hyperactivity  (Chapter  xv). 

In  many  cases  there  has  been  inflammation  in  the  Fallopian  tubes,  result- 
ing in  peritoneal  exudate  and  adhesions.  These  adhesions  fasten  the  uterus 
more  or  less  firmly  in  its  abnormal  position.  They  may  hold  the  uterus  almost 
immoA^able,  or  they  may  be  so  long  as  to  permit  the  uterus  much  latitude  in 
movement,  but  will  not  permit  it  to  come  entirely  forward.  Again,  if  the 
adhesion  is  to  a  movable  structure,  such  as  an  intestinal  coil  or  the  sigmoid, 
the  uterus  may  be  brought  forward  temporarily  but  is  soon  drawn  back 
into  the  abnormal  position. 

There  is  a  rare  condition  known  as  "retrodisplacement  with  anteflexion," 
in  which  an  anteflexed  uterus,  while  maintaining  its  anteflexion,  becomes 
turned  backward  so  that  the  fundus  lies  in  the  posterior  part  of  the  pelvis. 

Symptoms 

The  symptoms  accompanying  retrodisplacement  of  the  uterus  are  due 
principally  to  the  complications.  There  has  been  some  question  as  to  whether 
■uncomplicated  retrodisplacement  causes  any  symptoms.  It  may  be  said  that 
retrodisplacement,  as  met  Avith  in  actual  work,  is  rarely  without  symptoms. 
Occasionally  a  uterus  is  found  in  backward  displacement  without  any  symp- 
toms referable  directly  or  indirectly  to  it.  But  as  a  rule,  retrodisplacement 
causes  symptoms  or  aggravates  symptoms  due  to  some  other  disturbance. 

The  principal  symptoms  are  backache,  a  sense  of  weight  in  the  pelvis, 
and  MENORRHAGIA,.  Sometimes  only  one  and  sometimes  only  two  of  these 
symptoms  are  present,  but  most  frequently  all  of  them  are  complained  of. 

In  the  menorrhagia,  the  increase  in  the  menstrual  flow  is  usually  moderate 
only,  and  more  marked  in  the  amount  than  in  the  duration.  It  is  not  always 
present.  In  a  certain  proportion  of  the  patients,  the  menstrual  flow  remains 
unchanged,  and  in  some  it  is  diminished. 

Sometimes  in  young  women,  the  menorrhagia  is  the  only  symptom.  This 
menorrhagia    from   retrodisplacement   may  be   the    cause    of   delayed   meno- 


RETRODISPLACEMENT    OF    THE   UTERUS  675 

pause.  When  the  menorrhagia  is  pronounced  and  long  continued,  it  leads 
to  severe  anemia  and  marked  deterioration  of  the  general  health. 

The  backache  is  usually  located  low  over  the  sacrum  and  occasionally 
there  is  also  much  pain  in  the  region  of  the  coccyx  (coccygodynia,) .  Occa- 
sionally the  backache  extends  higher  along  the  spine.  It  is  more  commonly 
found  in  long-standing  retrodisplacement  and  in  the  complicated  cases — 
particularly  those  complicated  with  pelvic  inflammation.  Painful  menstrua- 
tion present  is  not  so  evidently  due  to  the  displacement,  as  is  the  menorrhagia. 

Leucorrhea  is  usually  present,  but  is  due  to  the  displacement  only  sec- 
ondarily, being  caused  by  the  chronic  congestion  of  the  endometrium  and 
resulting  excessive  glandular  secretion  and  endometrial  hyperplasia.  Bladder 
and  rectal  disturbances  are  sometimes  present,  especially  when  the  uterus  is 
large  and  the  fundus  is  displaced  far  down  in  the  cul-de-sac,  compressing  the 
rectum  or  pressing  the  cervix  forward  against  the  bladder. 

Sterility  is,  in  some  cases,  apparently  due  to  retrodisplacement,  though 
not  as  frequently  as  to  anteflexion  of  the  cervix  and  the  associated  conditions. 
Not  infrequently  in  a  married  woman  who  has  been  long  sterile,  pregnancy 
follows  correction  of  the  displacement.  Occasionally  the  pregnancy  follows 
so  promptly  as  to  leave  little  doubt  that  the  sterility  was  occasioned  by  the 
displacement  itself  (compression  of  the  tubes?)  and  not  by  any  associated  in- 
flammatory trouble  in  the  cervix  or  body  of  the  uterus. 

Repeated  Abortion  without  apparent  cause  is  another  condition  that 
should  arouse  suspicion  of  uterine  retrodisplacement.  Reflex  symptoms, 
headache  of  various  kinds  and  stomach  disturbance  or  functional  nervous 
disturbance,  are  occasionally  apparently  due  to  a  retrodisplacement,  but  on 
the  whole  the  frequency  of  reflex  symptoms  is  probably  exaggerated. 

Diagnosis 

The  symptoms  mentioned  are  common  to  many  diseases  and  hence  are 
not  at  all  distinctive  of  retrodisplacement.  The  diagnosis  of  retrodisplace- 
ment must  rest  upon  the  physical  examination.  In  examining  the  patient  it 
is  found  usually  that  the  cervix  is  lower  and  farther  forward  than  is  normal, 
and  that  it  also  points  forward. 

When  making  the  bimanual  examination,  search  is  made  for  the  body  of 
the  uterus  in  its  normal  location,  by  placing  the  ends  of  the  fingers  in  the 
vagina  in  the  front  of  the  cervix  and  pushing  the  cervix  upward  and  back- 
ward and  at  the  same  time  pressing  the  fingers  of  the  other  hand  into  the 
pelvis  from  above.  In  retrodisplacement  it  is  not  there  (Fig.  65).  Then 
placing  the  vaginal  fingers  back  of  the  cervix  and  making  bimanual  examina- 
tion (Figs.  66,  67),  a  mass  is  found  back  of  the  cervix,  which  is  about  the  size 
and  shape  of  the  body  of  the  uterus  and  apparentlj^  continuous  with  the 
cervix.    This  is  the  body  of  the  uterus  in  its  backward  position. 

If  the  uterus  is  in  only  the  first  degree  of  retrodisplacement  (Fig.  323), 


676 


DISPLACEMENT    OF    THE    UTERUS 


the  fundus  may  be  so  high  as  to  be  out  of  reach  of  the  vaginal  fingers,  and  yet 
far  enough  back  to  be  out  of  reach  of  the  fingers  above.  The  difficulty  is  much 
increased  if  the  patient  holds  the  abdominal  muscles  rather  tense.  In  these 
cases  the  body  of  the  uterus  may  sometimes  be  raised  so  it  can  be  felt  by  the 
abdominal  hand  by  pushing  up  the  cervix  with  the  fingers  in  the  vagina.  This 
lifts  the  whole  uterus — body  and  all.  If  the  displacement  is  marked  (that  is, 
second  or  third  degree)  the  fundus  can  usually  be  felt  by  the  vaginal  fingers, 
back  of  the  cervix.  When  a  mass  is  felt  in  front  or  behind  the  cervix,  it 
must  then  be  determined  whether  or  not  it  is  the  corpus  uteri.  The  following 
conditions  may  cause  an  error  in  diagnosis. 

A  tumor  in  the  anterior  wall  of  the  uterus  (Fig.  80). 

A  tumor  in  the  posterior  wall  of  the  uterus  (Fig.  368). 

A  mass  in  the  cul-de-sac,  due  to  prolapsed  ovary  or  tube  (Fig.  367)  or  to 
an  inflammatory  exudate  (Fig.  377)  or  to  a  tumor. 


Fig.  584.     Attempting  to  Raise  the  Fundus  Uteri,  to  determine  whether  or  not  it  is  fixed.     This  is  also  the 
first  step  in  Bimanual  Replacement  of  the  uterus.      (Pryor — Gynecology.) 


The  differential  diagnosis  is  made  by  making  out  the  position,  size,  shape, 
consistency,  tenderness,  mobility  and  attachments  of  the  mass,  as  explained 
under  Gynecologic  Examination  (page  275). 

Determine  Mobility.  After  having  determined  that  the  body  of  the 
uterus  is  backward,  and  about  how  far  backward,  the  next  point  to  determine 
is  whether  or  not  it  is  freely  movable.  The  vaginal  fingers  are  pressed  well 
in  under  the  fundus  and  an  attempt  is  made  to  lift  it  (Fig.  584).  If  it  can  not 
be  raised  from  its  position,  it  is  fixed.  The  fixation  may  be  due  to  adhesions 
or  to  the  fundus  being  caught  under  the  promontory  of  the  sacrum.  To  de- 
termine which  condition  is  present,  catch  the  cervix  with  the  tenaculum 
forceps  and  pull  it  downward  and  forward  (Fig.  585).  This  maneuver  pulls 
the  uterus  forward  and  away  from  the  promontory.  Then,  while  holding  the 
uterus  in  that  position,  the  fundus  may  be  lifted  past  the  promontory  (Fig. 


RETRODISPLACEMENT    OF    THE   UTERUS 


677 


586),  provided  it  is  not  other Avise  held.  If  still  the  uterus  can  not  be  raised, 
it  is  probably  adherent — i.  e.,  fixed  in  its  false  position  by  adhesions,  the 
result  of  inflammation.  This  probability  is  increased  if  there  is  evidence  of 
inflammation  about  the  tube  on  either  side. 

There  is  one  other  condition  that  may  cause  the  uterus  to  be  held  in  its 


Fig.   585.     Bimanual    Replacement.      Catching   the    Cervix    and    Pulling   Forward   the    Uterus,    so    the    fundus 
will  be   clear  of  the   sacral   promontory.      (Kelly — Operative   Gynecology.) 


Fig.   586.      Bimanual   Replacement.      Raising   the   Fundus   Uteri  past   the   sacral   promontory. 

(Pry  or — Gynecology.) 


backward  position.  Sometimes  when  the  fundus  lies  low  in  the  cul-de-sac, 
the  sacro-uterine  ligaments  produce  some  constriction  above  it  and  prevent 
its  return.  This  action  of  the  sacro-uterine  ligaments  is  increased  if  the  cer- 
vix be  strongly  pulled  upon.  This  is  a  rare  condition  and  is  possible  only 
when  the  uterus  is  in  the  third  degree  of  retrodisplacement. 


678 


DISPLACEMEXT    OF    THE    UTERUS 


Complications.     There  are  several  conditions  that  frequently  accompany 
retrodisplacement  and  that  must  be  taken  into  consideration. 


Laceration  of  pelvic    floor. 

Laceration  of  cervix. 

Endometritis. 

Salpingitis,  Avitli  or  vithont  exudate  and  adhesions. 

Tumors,  uterine  and  ovarian. 


Fig.   587.     Bimanual  Replacement.     Vv'orking  the  Abdominal  Fingers  down  over  the  sacral  promontory,  so  as 
to  get  behind  the  fundus  uteri   and  bring  it  forward.      (Pryor — Gynecology.) 

The  last  two  mentioned  may  cause  trouble  in  determining  the  exact  loca- 
tion of  the  body  of  the  uterus.  In  examining  a  patient,  do  not  stop  -^vhen  you 
find  one  lesion  but  make  a  thorough  examination  and  find  all  the  lesions 
present. 

Treatment 

If  there  are  no  symptoms,  no  treatment  is  needed.  But  the  patient  should 
be  kept  under  observation  so  that  if  symptoms  do  develop,  effective  treatment 
may  at  once  be  instituted  before  the  case  has  run  along  and  developed  com- 
plications. 

The  treatment  to  be  adopted  depends  on  vhether  the  uterus  is  movable  or 
adherent. 

When  the  Uterus  Is  Movable 

In  a  case  of  retrodisplacement  vith  movable  uterus,  the  first  step  in  the 


TREATMENT    OF    RETRODISPLACEMENT 


679 


treatment  is  to  replace  the  uterus  to  its  proper  position.  There  are  two  ways 
of  doing  this — by  bimanual  manipulation  or  by  employment  of  the  knee-ehest 
posture. 

Bimanual  Manipulation.  By  the  manipulation  employed  in  the  bimanual 
examination,  the  uterus  is  often  replaced. 

If  it  can  not  be  replaced  by  the  ordinary  bimanual  examination  methods, 
then  catch  and  draw  down  the  cervix  with  a  tenaculum  forceps  (Fig.  585), 
and  raise  the  fundus  as  high  as  possible  with  the  fingers  in  the  vagma.  Then 
press  the  abdominal  hand  deeply  into  the  back  part  of  the  pelvis,  locate  the 
promontory  and  then  work  along  it  into  the  pelvis  back  of  the  uterus  (Figs. 
586,587).  The  fundus  uteri  is  then  brought  forward  and  at  the  same  time 
the  cervix  is  carried  backward,  as  shown  in  Fig.  588.     After  bringing  the 


Fig.   588.     Bringing   the    Fundus    Uteri    forward   and   pushing   the   Cervix   backward   and    tipward. 

Operative    Gynecology.) 


(Kelly— 


fundus  forward,  bend  it  well  down  over  the  vaginal  fingers  as  sIioa^ti  in  Fig. 
589,  in  order  to  take  out  any  backward  flexion  that  may  be  present. 

To  carry  out  these  manipulations  successfully,  the  abdominal  walls  must 
be  relaxed  and  the  uterus  not  very  tender.  If  the  patient  has  a  thick  layer 
of  adipose  tissue,  the  examining  fingers  sometimes  can  not  get  near  enough  to 
the  uterine  body  to  manipulate  it  satisfactorily.  If  the  patient  holds  the 
abdominal  walls  tense,  on  account  of  pain  or  nervousness,  the  abdominal 
fingers  can  not  reach  the  uterus.  If  the  uterus  is  inflamed  and  tender,  the 
pressure  necessary  to  these  manipulations  causes  too  much  pain. 

Knee-chest  Posture.  "When  the  uterus,  though  movable,  can  not  be  re- 
placed by  the  bimanual  manipulations,  the  knee-chest  posture  may  be  used 
(Fig.  445).     After  the  patient  has  been  placed  in  this  position   (with  the 


680 


DISPLACEMENT   OF    THE    UTERUS 


clothing  about  waist  thoroughly  loosened)  the  Sims  speculum  is  introduced 
(Fig,  446).  The  cervix  is  then  caught  with  the  tenaculum  forceps  and  pulled 
forward.  This  brings  the  fundus  uteri  out  from  the  promontory  and  permits 
it  to  fall  forward  into  its  proper  position.  The  cervix  is  then  pushed  well 
backward  into  the  hollow  of  the  sacrum,  and  a  pessary  or  packing  is  put  in 
to  hold  it  there. 

The  method  of  replacement  by  sound  or  repositor  is  mentioned  only  to  be 
condemned.  The  sound  or  intrauterine  repositor  used  in  this  way  is  dangerous. 
A  uterus  that  is  not  adherent  can  usually  be  brought  forward  by  one  of  the  two 
methods  already  mentioned.     A  uterus  that  is  adherent  could  not  be  brought 


Fig.  589.  The  Uterus  brought  forward  into  position.  This  shows  also  the  method  of  taking  the 
backward  flexion  out  of  the  uterus,  by  bending  it  firmly  forward  over  the  vaginal  fingers.  (Kelly  Opera- 
tive  Gynecology.) 

forward  by  the  sound  or  repositor,  and  its  use  in  such  a  case  is  liable  to  lead  to 
inflammation  or  perforation  of  the  uterus. 

In  some  cases  the  uterus  and  adjacent  tissues  are  too  tender  to  permit 
the  manipulations  necessary  for  replacement.  In  such  a  case,  hot  vaginal 
douches,  purgatives  and  the  knee-chest  posture  morning  and  evening  for  a 
few  days,  may  diminish  the  tenderness  very  much.  In  such  a  case,  after  the 
knee-chest  posture  has  been  taken  morning  and  evening  for  a  few  days,  the 
uterus  may  be  found  forward  at  the  next  examination. 

Vaginal  Tamponade  with  the  patient  in  the  knee-chest  posture  or  in  the 


TREATMENT   OP    RETRODISPLACEMENT  681 

Sims  posture,  ^vitll  gauze  or  cotton,  every  second  or  third  day,  helps  to 
restore  the  uterus  to  its  normal  position.  Also,  in  cases  where  no  pessary  is 
at  hand,  the  uterus,  after  replacement,  may  be  held  in  place  temporarily  by 
packing  the  vagina  with  gauze  or  cotton  in  such  a  way  that  the  cervix  is  held 
well  back  in  the  pelvis.  Again,  when  a  pessary  has  to  be  removed  temporarily  for 
any  cause,  the  method  of  holding  the  uterus  by  packing  may  be  employed. 
This  method  does  very  wellfor  holding  the  uterus  in  position  for  a  short 
time,  but  the  packing  must  be  changed  every  few  days,  hence  the  method  is 
not  suitable  for  long-continued  use. 

The  Pessary.  After  the  uterus  has  been  replaced,  then  comes  the  problem 
of  holding  it  there.  The  most  convenient  and  efficient  device  for  this  pur- 
pose is  the  pessary.  In  uncomplicated  cases  this  is  often  all  that  is  needed. 
The  varieties  of  pessaries,  their  mode  of  action,  the  manner  of  their  introduc- 
tion and  their  after-care  are  given  in  detail  in  chapter  ni    (see  Pessaries). 

The  Thomas,  the  Smith  and  the  Hodge  pessaries  (Fig.  428)  are  the  ones 
to  be  used  for  retrodisplacement,  according  to  the  particular  indications 
given  for  each. 

In  some  cases  the  patient  is  made  fairly  comfortable  by  simple  support 
of  the  uterus  Avithout  replacement,  such  as  is  given  by  tampons  or  by  the 
inflated  ring  pessary  (Fig.  436).  Patients  sometimes  secure  these  inflated  ring 
pessaries  themselves,  from  friends  or  from  agents  or  through  advertise- 
ments, and  experience  so  much  relief  that  they  believe  themselves  cured. 
And  in  some  eases  there  is  considerable  benefit  persisting  for  some  time  after 
the  support  is  removed,  because  the  stretched  pelvic  tissues  have  gained  in 
tone  Avhile  the  uterus  was  supported.  The  relief  in  these  cases  comes  from 
the  relief  of  the  downward  dragging  of  the  uterus  as  a  whole,  for  there  is 
ordinarily  no  correction  of  the  retrodisplacement  (unless  the  patient  happens 
to  employ  the  knee-chest  posture  at  the  same  time).  It  is  far  preferable  in 
such  a  case  to  use  the  form  of  pessary  that  will  hold  the  uterus  in  normal 
position  and  thus  tend  to  permanent  relief. 

The  effect  just  noted  of  the  simple  support  of  the  uterus,  serves  to  show 
the  importance  of  the  slight  prolapse  in  these  cases  and  serves  to  show  also 
that  the  retrodisplacement,  as  a  factor  in  the  causation  of  the  symptoms 
and  as  a  factor  to  be  considered  in  the  treatment,  is  not  of  such  exclusive 
importance  as  one  would  infer  from  the  usual  teachings  on  this  subject.  The 
relief  that  follows  operative  replacement  and  permanent  correction  of  the 
retrodisplacement,  is  due  to  a  large  extent  to  the  simultaneous  elevation  of 
the  uterus  and  adnexa. 

In  some  cases  the  pessary  may  be  removed  in  a  few  weeks  and  the  uterus 
will  stay  in  position  without  further  attention.  In  other  cases  the  pessary 
must  be  worn  for  several  months,  being  removed  at  intervals,  as  explained  in 
Chapter  ni. 


682  DISPLACEMENT    OF    THE    UTERUS 

In  a  considerable  proportion  of  eases  in  Avhicli  the  uterus  is  movable,  the 
pessary  is  not  satisfactorv,  for  one  of  the  following  reasons : 
Laceration  of  the  pelvic  floor. 
Prolapsed  and  tender  ovary  or  tube. 
Nervousness. 

In  the  first  class  of  cases,  the  pessary  fails  to  keep  the  uterus  in  position. 
The  -weakening  of  the  pelvic  floor  permits  the  anterior  end  of  the  pessary  to 
sink  below  its  point  of  support.  It  sinks  down  to  a  wider  part  of  the  pubic 
arch  and  then  slips  out  of  the  vaginal  opening.  The  cervix  uteri  then  sinks 
forward  and  the  fundus  goes  backward. 

AVhen  an  ovary  has  prolapsed  into  the  posterior  cul-de-sac  the  pessary 
presses  on  it  and  causes  pain.  The  same  thing  happens  if  an  enlarged  and 
tender  tube  drops  into  this  situation,  or  if  there  is  an  inflammatory  exudate 
there.    In  either  case,  the  pessary  causes  so  much  pain  that  it  can  not  be  worn. 

There  is  occasionally  a  case  in  which,  though  the  i3essary  holds  the  uterus 
in  position  and  causes  no  particular  pain,  it  makes  the  patient  uncomfortable 
and  nervous  to  such  an  extent  that  its  use  is  not  satisfactory. 

In  all  such  cases  other  measures  for  holding  the  uterus  in  position  must 
be  employed. 

Operative  Treatment.  AYhen  there  are  troublesome  symptoms  that  are 
not  relieved  by  the  measures  previously  mentioned,  operative  treatment  is 
required.  The  various  classes  of  operative  measures  are  mentioned  further 
along  (page  685). 

In  order  that  the  operative  treatment  may  prove  satisfactory,  the  patient 
should  be  put  through  a  most  careful  and  thorough  pelvic  examination,  that 
the  exact  cause  of  the  persistence  of  the  displacement  may  be  accurately  de- 
termined, and  the  form  of  operative  treatment  selected  accordingly. 

In  a  large  proportion  of  the  patients  who  have  borne  children,  there  will 
be  found  a  relaxed  condition  of  the  pelvic  floor  and  of  the  broad  ligaments 
and  sacro-uterine  ligaments.  It  is  evident  that  in  such  a  case,  the  simple 
bringing  of  the  fundus  uteri  forward  and  fastening  it  there  is  only  a  small 
part  of  the  necessary  work.  The  pelvic  floor  must  be  strengthened,  and 
some  means  must  be  used  also  to  lift  up  the  uterus  and  thus  overcome  the 
prolapse  due  to  the  relaxation  of  all  the  supports  of  the  organ.  In  many  of 
these  cases  the  uterus  is  large  and  heavy  from  subinvolution  and  is  the  seat 
of  chronic  endometritis. 

Wlieii  the  Uterus  Is  Adherent 

AYlien  the  fundus  uteri  can  not  be  brought  forward  by  the  methods  pre- 
viously described  and  no  tumor  that  is  responsible  for  the  fixation  can  be 
felt,  it  is  assumed  that  the  uterus  is  ' "  adherent, ' '  i.  e.,  held  in  its  abnormal 
position  by  the  products  of  pelvic  inflammation,  affecting-  the  tube  or  the  peri- 
toneum or  the  connective  tissue.    The  flxation  mav  be  so  close  that  the  fundus 


TREATMENT    OP   RETRODISPLACEMENT  683 

can  not  be  moved  appreciably,  or  it  may,  on  the  other  hand,  permit  consid- 
erable movement  in  various  directions,  but  not  enough  to  allow  the  fundus 
uteri  to  be  brought  entirely  forward. 

For  the  purposes  of  treatment  it  is  convenient  to  divide  these  cases  of 
adherent  retrodisplacement  into  two  classes — (1)  those  in  which  the  inflam- 
mation is  acute  or  subacute,  and  (2)  those  in  which  it  is  chronic  or  has  prac- 
tically disappeared,  leaving  only  the  sequelae. 

Inflammation  Acute.  These  cases  present,  in  addition  to  the  retrodisplace- 
ment of  the  uterus,  the  usual  symptoms  and  signs  of  acute  or  subacute  pelvic  in- 
flammation. The  symptoms  presented  by  the  patient  are  due  principally  to  the 
inflammation,  and  the  treatment  is  at  first  directed  wholly  to  that.  The 
general  and  special  measures  for  acute  pelvic  inflammation  (see  Chapter  x) 
are  used  and  continued  for  several  weeks,  until  all  acute  symptoms  have 
disappeared. 

No  operation  or  other  direct  disturbance  of  the  tissues  for  the  purpose 
of  bringing  the  uterus  forward  is  indicated  in  this  acute  stage.  All  operative 
measures  are  to  be  postponed,  except  so  far  as  such  measures  may  be  indicated 
directly  by  the  inflammation.  The  patient  is  treated  for  the  pelvic  inflamma- 
tion the  same  as  though  she  had  no  retrodisplacement. 

When  the  inflammation  subsides,  the  troublesome  symptoms  may  dis- 
appear to  such  an  extent  that  no  treatment  for  the  retrodisplacement  is  re- 
quired. It  is  the  relief  of  pain  and  discomfort  that  the  patient  seeks  and 
when  this  can  be  secured  simply  by  the  relief  of  the  inflammatory  trouble,  it 
is  not  necessary  to  disturb  the  uterus.  In  fact,  as  a  rule,  anything  in  that 
direction  short  of  removal  of  the  inflammatory  focus,  will  tend  to  stir  up 
again  the  troublesome  symptoms. 

Most  of  these  patients  require  operative  treatment  later,  but  occasionally 
there  is  a  patient  who  continues  to  feel  perfectly  well  after  she  recovers  from 
the  attack  of  pelvic  inflammation — she  can  Avork  hard,  goes  as  much  as  she 
pleases,  and  she  is  symptomatically  a  well  woman.  It  has  been  the  author's  ex- 
perience that  this  permanent  or  long-continued  freedom  from  troublesome  symp- 
toms without  satisfactory  replacement  of  the  uterus,  occurs  more  frequently  in  the 
cases  of  retrodisplacement  with  a  fixed  uterus  than  in  those  with  a  movable 
uterus,  though  it  is  not  very  frequent  in  either.  The  fixation  prevents  the 
constant  downward  dragging  (beginning  prolapse)  which  produces  a  large 
part  of  the  distress  in  the  ordinary  cases  of  large  heavy  retrodisplaced 
mobile  uteri. 

Operation  is  required  however  in  a  majority  of  these  eases  sooner  or  later, 
either  because  of  a  persisting  focus  of  inflammation,  with  chronic  invalidism, 
or  because  of  the  sinking  and  dragging  of  the  heavy  retrodisplaced  uterus 
on  the  damaged  and  sensitive  adnexa  or  adjacent  structures.  In  the  case  of 
a  partially  movable  uterus,  the  wearing  of  a  pessary  (for  example,  the  inflated 
ring  pessary)  that  holds  the  heavy  uterus  up  some,  will  sometimes  give  con- 


684  DISPLACEMENT   OF    THE   UTERUS 

siderable  relief.  Such  a  pessary  prevents  the  constant  dragging  of  the  uterus 
on  its  supports  and  on  the  sensitive  adnexa,  and  in  that  way  gives  relief, 
though  there  is  no  correction  of  the  retrodisplacement. 

Chronic  Inflammation.  In  the  chronic  cases,  fix^,tion  of  the  retrodisplaced 
uterus  is  usually  due  to  inflammation  beginning  in  a  Fallopian  tube,  conse- 
quently it  is  frequently  accompanied  by  salpingitis  and  an  inflammatory 
exudate  involving  one  or  both  tubal  regions.  There  may  be  a  collection  of  pus 
in  a  tube  or  in  the  mass  of  exudate  about  the  tube,  or  there  may  be  only  a 
mass  of  inflammatory  exudate  without  pus,  or  there  may  be  only  adhesions. 
If  the  previous  inflammation  was  in  the  connective  tissue,  there  will  be  infil- 
tration remaining  from  the  pelvic  cellulitis  (parametritis).  In  either  case, 
the  uterus  is  found  in  an  abnormal  position  and  can  not  be  replaced  by  the 
methods  previously  described. 

In  these  cases,  considerable  relief  may  be  given  by  measures  that  tend 
to  allay  the  accompanying  pelvic  inflammation  and  that  stretch  the  adhesions 
and  that  support  the  uterus  to  some  extent.  The  palliative  measures  men- 
tioned under  chronic  pelvic  inflammation  (see  Chapter  x)  may  be  employed. 
For  support,  the  inflated  ring  pessary  is  useful  (Fig.  436). 

For  stretching  the  adhesions,  and  infiltrated  tissues,  in  an  endeavor  to 
restore  the  uterus  to  its  normal  position,  pelvic  massage  and  pressure  treatment 
are  useful  (pages  405,  411).  Cases  with  slight  adhesions,  and  especially 
cases  in  which  the  uterus  is  held  in  its  abnormal  position  by  the  sequelae  of 
a  pelvic  cellulitis  only,  may  be  benefited  thereby,  and  in  such  cases  these  meas- 
ures may  be  given  a  thorough  trial.  But  in  the  majority  of  cases  of  fixed 
retrodisplacement,  the  inflammatory  lesions  are  of  such  character  that  this 
attempted  stretching  can  do  no  good  and  may  do  much  harm.  The  propor- 
tion of  cases  in  which  permanent  relief  of  the  pelvic  distress  can  be  secured, 
in  this  way,  is  very  small.  At  least,  such  has  been  the  observation  of  the  author 
who  has  studied  this  class  of  cases  month  after  month  and  year  after  year. 
And  he  has  endeavored  to  find  for  each  variety,  the  treatment  that  would 
give  the  required  relief  with  the  least  danger  to  the  patient  and  the  least 
sacrifice  of  tissue. 

In  the  SEQUELAE  OF  CELLULITIS,  without  associatcd  peritoneal  involve- 
ment, one  may  expect  softening  and  stretching  of  infiltrated  tissue,  increased 
mobility  of  the  uterus,  improvement  of  the  intrapelvic  circulation  (lymph 
and  blood),  relief  of  distressing  symptoms,  and  in  some  cases  a  complete 
restoration  of  the  uterus  to  its  normal  position. 

When  there  is  a  peritoneal  or  tubal  involvement,  as  evidenced  by  a 
history  of  attacks  of  pelvic  peritonitis  and  by  induration  in  one  or  both  tubal 
regions,  little  can  be  expected  from  stretching  or  kneading  of  the  affected  tis- 
sues. Even  though  all  acute  inflammation  has  apparently  long  since  disap- 
peared, these  tubal  and  peritubal  and  periovarian  lesions  are  usually  ag- 
gravated rather  than  improved  by  massage  or  pressure  treatment.     As  pre- 


OPERATIVE    TREATMENT   OF   RETRODISPLACEMENT  685 

viously  explained,  there  is  present  in  nearly  all  these  cases  a  focus  of  active 
irritation  in  the  tubes.  Nature  may  take  care  of  this  and,  if  assisted  by  rest 
and  general  measures,  may  limit  it  so  that  it  causes  little  trouble  or  may 
eradicate  it  entirely,  but  pelvic  massage  and  pressure  treatment  are  likely 
to  interfere  with  this  natural  cure  instead  of  aiding  it,  except  as  to  hastening 
the  absorption  of  outlying  masses  of  exudate. 

Operative -Treatment  is  indicated  in  practically  all  cases  of  fixed  retro- 
displacement,  except  in  those  in  which  the  fixation  is  due  wholly  to  the 
sequelae  of  pelvic  cellulitis  or  scar-tissue  about  the  vaginal  vault.  Of  course, 
operation  is  required  only  in  those  cases  in  which  troublesome  symptoms 
persist  in  spite  of  treatment  for  the  pelvic  inflammation. 

The  objects  of  the  operative  treatment  are  two,  first  the  removal  of 
products  of  inflammation  and  of  damaged  organs  as  far  as  necessary  and, 
second,  the  lifting  and  bringing  forward  of  the  body  of  the  uterus  and 
fastening  it. 

These  objects  may  be  accomplished  by  either  vaginal  section  or  abdom- 
inal section.  There  are  certain  eases  in  which  vaginal  section  is  the  preferable 
method  of  approach  and  there  are  other  cases  in  Avhich  abdominal  section  is 
clearly  indicated.  Between  these  special  cases  at  each  extreme  there  is  a 
large  middle  class  of  the  chronic  cases  in  which  the  Avork  may  be  satisfac- 
torily accomplished  by  either  route.  Some  operators  prefer  one  and  some  the 
other  route.  In  the  author's  opinion  in  the  majority  of  these  cases  abdominal 
section  is  preferable.  It  gives  a  much  better  chance  for  an  accurate  deter- 
mination of  what  structures  should  be  removed  and  what  should  be  left.  It 
gives  a  better  chance  also  for  complete  and  accurate  removal  of  diseased 
structures  without  injury  to  tissues  that  are  left.  Furthermore,  it  permits 
the  fastening  of  the  uterus  well  forward  in  such  a  way  that  it  and  its  adnexa 
are  satisfactorily  elevated  as  well  as  brought  forward. 

The  portion  of  the  operative  work  dealing  with  the  inflammatory  trouble 
will  be  mentioned  under  chronic  pelvic  inflammation  (Chapter  x).  The  opera- 
tive measures  for  the  correction  of  the  displacement,  after  the  inflammatory 
trouble  has  been  taken  care  of,  are  mentioned  below: 

Operative  Measures 

The  operative  measures  required  in  patients  with  retrodisplacement  of 
the  uterus  may  be  divided  into  three  groups — (a)  measures  for  reducing  the 
inflammation  and  enlargement,  of  the  uterus  and  for  restoring  the  pelvic  floor, 
(b)  measures  for  relieving  or  removing  the  pelvic  inflammation,  and  (c) 
measures  for  bringing  the  uterus  and  adnexa  forward  and  upward  and 
fastening  them  there.  The  measures  of  the  first  and  second  classes  are  given 
elsewhere,  under  the  respective  diseases. 

The  operative  measures  for  holding  the  uterus  forward  are  very  nu- 
merous, the  number  running  well  above  a  hundred.     There  are,  however,  cer- 


686  DISPLACEMENT   OF    THE   UTERUS 

tain  representative  operations  that  may  be  mentioned  in  order  to  give  an 
idea  of  the  various  methods  of  approach  and  the  various  structures  utilized. 
The  methods  of  approach  are  (A)  through  the  inguinal  canals,  (B)  through  a 
median  abdominal  incision,  and  (C)  through  the  vagina. 

A.  Throug'h  the  Inguinal  Canals. 

1.  Extraperitoneal  Shortening  of  the  Round  Ligaments    (Alexander- 

Adams  Operation).  An  incision  is  made  over  the  inguinal  canal  on 
each  side  and  the  round  ligament  is  isolated  and  drawn  out  suffi- 
ciently to  take  up  the  slack  and  bring  the  uterus  forward.  The 
ligaments  are  then  fastened  in  the  canals  by  sutures.  The  peritoneal 
cavity  is  not  opened. 

a.  Operation  is  entirely  extraperitoneal. 

b.  Utilizes  the  strong  proximal  portion  of  the  round  ligaments  for 

supporting  the  uterus. 

c.  Does  not  permit  the  breaking  up  of  adhesions. 

d.  Does  not  permit  direct  exploration  of  the  pelvis,  to  ascertain  ab- 

normal conditions  or  to  make  certain  that  the  uterus  comes 
satisfactorily  forward  without  complications. 

e.  Ligaments  pull  laterally  instead  of  forward  and  hence  permit 

return  of  displacement  when  there  is  much  backward 
tendency. 

2.  Inguinal  Celiotomy  with  Shortening  of  Eound  Ligaments    (Gold- 

spon  operation).  This  is  practically  the  same  as  the  Alexander 
operation,  except  that  the  peritoneal  cavity  is  opened  on  one  or  both 
sides. 

a.  Utilizes  the  strong  proximal  portion  of  the  ligaments  for  sup- 

porting the  uterus. 

b.  Permits  partial  exploration  of  the  pelvic  cavity  and  the  break- 

ing of  light  adhesions. 

c.  Ligaments  pull  laterally  instead  of  forward. 

d.  Has  the  disadvantage  of  median  abdominal  section  (peritoneal 

cavity  opened)  without  the  advantages  (through  exploration, 
safe  removal  of  diseased  structure,  forward  pull  of  new  liga- 
ments). 

B.  Through  Median  Abdominal  Section.     Pertaining  to  all  the  operations  in 

this  class  are  the  advantages  of  thorough  exploration  of  the  pelvis  and 
lower  abdomen  and  the  safe  removal  of  diseased  structures,  including  the 
appendix  when  necessary.     The  special  advantages  and  disadvantages 
of  each  submethod  are  indicated  below. 
1.  Fastening  the  Fundus  Uteri  Directly  to  the  Abdominal  Wall. 
I.  Ventro-fixation.     The  fundus  uteri  is  scarified  and  sutured  di- 
rectly (without  intervening  peritoneum)   to  the  subperitoneal 
aponeurotic  structure  of  the  abdominal  wall. 


OPERATIVE    TREATMENT   OF    RETRODISPLACEMENT  687 

a.  The  uterus  is  fastened  very  firmly  forward,  so  that  there 

is  hardly  a  possibility  of  return  of  the  displacement. 

b.  Causes  serious  interference  with  the  development  of  the 

uterus  in  pregnancy,  hence  is  not  permissible  ordinarily 

in  the  child-bearing  period, 
n.  Ventro-suspension.  The  fundus  uteri  is  fastened  by  small  silk 
sutures  to  the  peritoneum  of  the  abdominal  wall.  The  idea  is 
to  secure  the  formation  of  a  band  of  tissue  which  will  hold  the 
fundus  forward  (suspend  it  from  the  wall)  but  will  not  inter- 
fere with  the  development  of  the  uterus  in  pregnancy.  (Some 
prefer  to  pass  the  suspension  sutures  through  the  utero-ovarian 
ligaments  rather  than  directly  through  the  uterine  tissue). 

a.  Direct  forward  pull,  holding  the  uterus  well  forward. 

b.  Does  not  interfere  with  the  development  of  uterus  in  preg- 

nancy. 

c.  Uncertainty   of  ultimate  result.      The   suspending   band 

may  become  so  stretched  that  it  permits  return  of  the 
displacement  or,  on  the  other  hand,  an  unusual  amount 
of  scar-tissue  may  form  causing  a  firm  fixation  of  the 
uterus  to  the  abdominal  wall,  which  would  seriously 
interfere  with  the  pregnancy. 

d.  There  is  a  free  band  in  the  abdominal  cavity,  occasionally 

leading  to  intestinal  obstruction. 
Intraabdominal  Shortening  of  Round  Ligaments. 

I.  Folding  of  the  round  ligaments  in  various  ways. 

a.  No  interference  with  pregnancy,   as  the  round  ligaments 

enlarge  with  pregnancy  and  undergo  involution  after- 
ward. 

b.  No  free  band  in  abdominal  cavity. 

c.  The  strain  comes  on  the  weak  part  of  the  ligament  near 

the  inguinal  ring.  This  is  likely  to  stretch  and  permit 
return  of  the  displacement. 

II.  Drawing  the  round  ligaments  through  a  hole  in  the  broad  liga- 

ment of  each  side  and  fastening  them  together  back  of  the 
uterus. 

a.  Secures  excellent  elevation  of  the  uterus  and  adnexa. 

b.  The  strain  falls  on  the  weak  portion  (distal  portion)   of 

round  ligaments. 

III.  Suturing  middle  of  round  ligaments  to  the  peritoneum  of  the 

anterior  abdominal  wall. 

a.  Peritoneal  adhesions  stretch  in  time  and  are  likely  to  per- 
mit return  of  the  displacement. 


688  displacement  of  the  uterus 

3.  Transplantation  of  Round  Ligaments  into  the  Abdominal  Wall, 

The    intraabdominal    portion    of    each    ligament    is    drawn    into    the 
musciilo-aponeurotic  layer  of  the  abdominal  wall  and  fastened  in  the 
median  incision    (the  median  incision  may  be  longitudinal  or  trans- 
verse).     The    shortened  ligament   leaves   the    abdominal   cavity   at 
different  points  in  the  different  classes  of  operations,  as  follows: 
I.  Out  through  the  aponeurotic  wall  at  the  internal  inguinal  ring, 
and  then  to  the  median  incision  (Sandberg,  Peterson,  Mont- 
gomery, Barrett  and  others). 

a.  Utilizes  the  strong  portion   (proximal  portion)    of  liga- 

ments for  supporting  the  uterus. 

b.  No  free  band  in  peritoneal  cavity. 

c.  Direction  of  pull  on  uterus  is  lateral  instead  of  forward, 

hence  the  displacement  is  likely  to  return  if  there  is 
much  backward  tendency. 
{    n.  Out  directly  through  the  rectus  muscle   (Gilliam  operation). 

a.  Utilizes  the  strong  proximal  portion  of  the  ligaments. 

b.  Direction  of  pull  is  directly  forward,  hence  holds  uterus 

and   adnexa  well  forward   and  upward,   against   even 
strong  baekAvard  tendency. 

c.  Can  be  used  even  when  the  round  ligaments  are  fixed  by 

inflammatory  infiltration  or  are  too  weak  to  be  used  for 
extensive  implantation. 

d.  Gives  two  free  bands  in  the  peritoneal  cavity,  which  may 

cause  intestinal  obstruction. 
m.  Out  directly  through  the  rectus  muscle,  with  the  addition  of  a 
suture  in  each  side  to  unite  the  distal  portion  of  the  round  liga- 
ment to  the  anterior  abdominal  wall  and  thus  close  the  open- 
ing through  which  an  intestinal  coil  might  slip  (Gilliam-Fergu- 
son  operation). 

a.  Utilizes  the  strong  portion  of  the  ligaments. 

b.  Direction  of  pull  is  directly  forward. 

c.  Can  be  used  even  wdth  fixation  of  the  round  ligaments 

or  setious  attenuation  of  the  same. 

d.  No  free  band  in  peritoneal  cavity. 

e.  Operative  manipulations  more  complicated  and  time-con- 

suming than  necessary,  where  the  round  ligaments  are 

in  good  condition. 

V/iv.  Out  through  the  peritoneum  near  the  internal  inguinal  ring,  then 

along  in  the  subperitoneal  tissue  and  out  through  the  rectus 

muscle    (Gilliam-Crossen  operation).     The  details  of  this   are 

explained  later  (Figs.  590,  591,  592). 

a.  Utilizes  the  strong  portion  of  the  ligaments. 


OPERATIVE    TREATMENT   OF   RETRODISPLACEMENT  689 

b.  Direction  of  pull  is  forward.    It  is  not  so  directly  forward 

as  in  the  regular  Gilliam  operation,  but  sufficiently  so  to 
answer  the  purpose  in  practically  all  cases. 

c.  No  free  band  in  peritoneal  cavity. 

d.  Operative  manipulations  are  few  and  quickly  executed. 

e.  Not  applicable  in  cases  of  fixation  of  round  ligaments  nor 

when  the  ligaments  are  seriously  attenuated. 

4.  Keefing  THE  Broad  Ligaments. 

a.  This  lifts  the  uterus  and  adnexa. 

b.  Does  not  hold  fundus  uteri  well  forward. 

5.  Shortening    of    Sacro-uterine    Ligaments    (through    the    abdominal 

incision). 

a.  Draws  the  cervix  uteri  well  back  and  upward  in  the  pelvis,  which 

is  an  important  consideration  in  cases  in  which  the   cervix 
comes  far  forward. 

b.  When  used  alone  it  does  not  satisfactorily '  elevate  and  hold  for- 

ward the  fundus  uteri  and  adnexa.    It  is  used  when  necessary 
in  combination  with  some  anterior  operation  for  holding  the 
fundus  forward. 
C.  Through  the  Vagina.    The  vaginal  operations  in  general  have  the  advantage 
that  they  are  easily  combined  with  the  vaginal  work  previously  men- 
tioned as  necessary  in  a  considerable  proportion  of  the  cases  of  retrodis- 
placement.    Again,  there  is  less  handling  of  peritoneal  surfaces  and,  con- 
sequently, less  shock  and  less  danger  of  peritonitis. 

On  the  other  hand,  they  have  the  disadvantage  that  they  do  not  pro- 
vide for  satisfactory  elevation  of  the  fundus  uteri  and  adnexa  nor  for  the 
decided  pull  forward  and  upward  that  is  necessary  when  there  is  a  strong 
backward  tendency.  Again,  pathologic  conditions  in  the  pelvis  or  lower 
abdomen  can  not  be  so  well  determined  nor  so  safely  and  accurately 
treated. 

1.  Vagino-fixation.  The  peritoneal  cavity  is  opened  by  anterior  vaginal 
section  and  the  fundus  uteri  fastened  forward  by  sutures  passing 
through  the  vaginal  wall  and  the  anterior  surface  of  the  uterus. 

a.  Fixes  the  fundus  uteri  well  forward  and  throws  the  cervix 

backward. 

b.  Does  not  provide  for  satisfactory  elevation  of  the  uterus  and 

adnexa. 

c.  Uncertainty  of  ultimate  result.     As  formerly  carried  out  it 

caused  serious  trouble  in  pregnancy.  Improvements  in  the 
technic  have  lessened  this  danger,  but  haA^e  not  eliminated 
it  entirely. 

When  the  uterus  is  fastened  forward  securely  enough  to 
insure  its  staying  there,  an  excessive  amount  of  scar  may 


690  DISPLACEMENT    OF    THE    UTERUS 

form  and  cause  trouble  in  pregnancy.  On  the  other  hand, 
when  the  operation  is  so  conducted  as  to  practically  elimi- 
nate this  danger,  the  fixation  is  likely  to  be  insecure  and 
there  may  be  return  of  the  displacement. 

2.  Vesico-fixation.    The  peritoneal  cavity  is  opened  by  anterior  vaginal 

section  and  the  fundus  uteri  is  brought  forward  and  sutured  to  the 
vesical  peritoneum. 

a.  Fundus  brought  well  forward. 

b.  Does  not  provide  for  satisfactory  elevation  of  the  uterus  and 

adnexa. 

c.  The  peritoneal  adhesions  are  likely  to  stretch  and  permit  re- 

turn of  the  displacement. 

3.  Shortening  the  Eound  Ligaments  through  Vaginal  Incision,  by 

folding  them  in  various  ways. 

a.  Brings  fundus  uteri  forward. 

b.  Does  not  provide  for  satisfactory  elevation  of  uterus  and 

adnexa. 

c.  Uterus  is  suspended  by  the  weak  portion  (distal  portion)  of 

the  ligaments. 

d.  Direction  of  pull  is  lateral  instead  of  forward. 

4.  Anterior  Coaptation  of  the  Broad  Ligaments.    The  bladder  is  sepa- 

rated from  the  uterus,  as  in  anterior  vaginal  section,  and  then  the 
strong  tissues  in  the  lower  part  of  each  broad  ligament  are  brought 
together  in  the  median  line  in  front  of  the  cervix  and  sutured  there. 
This  operation  promises  much,  both  in  cases  of  retrodisplacement 
and  in  prolapse  of  the  uterus.  It  is  a  comparatively  new  operation, 
but  there  are  already  several  modifications.  Its  effects  are  as  fol- 
lows: 

a.  Cervix  is  elevated  and  held  well  back  in  the  pelvis.     This  is 

sufficient  in  some  cases  to  keep  the  fundus  uteri  forward  and 
to  lessen  the  dragging  sufficiently  to  relieve  the  symptoms. 

b.  It  does  not  strongly  elevate  the  fundus  and  adnexa. 

c.  Like  the  other  vaginal  operations,  it  fails  to  provide  for  the 

thorough  exploration  and  operative  treatment  of  pathologic 
conditions  in  the  pelvis  and  lower  abdomen. 

5.  Shortening    of    Sacro-uterine    Ligaments    through    a    Posterior 

Vaginal  Incision. 

a.  Draws  cervix  well  back  and  upward  and  throws  fundus  for- 

ward. 

b.  Does  not  satisfactorily  elevate  the  fundus  uteri  and  the  adnexa, 

c.  Tubal  and  appendiceal  complications  can  not  be  so  satisfactorily 

determined  nor  so  accurately  treated. 


operative  treatment  of  retrodisplacement  691 

6.  Posterior  Vaginal  Section,  with  Packing  of  Cervix  Back  to  Form 
Adhesions  (Pryor). 

a.  Cervix  is  fastened  well  backward  and  upward  and  the  fundus 

pushed  forward. 

b.  Very  uncertain  as  to  whether  satisfactory  posterior  fixation  of 

the  cervix  will  be  secured.  It  may  be  tried  when  the  cul-de- 
sac  is  opened  for  other  cause.  The  packing'  may  be  used  ad- 
vantageously when  the  sacro-uterine  ligaments  are  shortened 
by  vaginal  section. 

c.  Does  not  provide  for  satisfactory  elevation  of  the  fundus  uteri 

and  adnexa. 

Choice  of  Operation 

What  operation  is  preferable  in  a  particular  case  depends  on  the  conditions 
present  in  that  case. 

When  the  uterus  is  freely  movable  and  stays  forward  well  with  a  pessary,  but 
the  wearing  of  the  pessary  is  not  satisfactory  because  of  tenderiiess  or  nervous- 
ness or  other  discomfort,  the  uterus  may  be  held  forward  by  the  extraperitoneal 
shortening  of  the  round  ligaments  (Alexander- Adams  operation)  or  by  vesico- 
fixation.  The  former  is  preferable  usually  because  it  gives  better  elevation  of 
the  uterus  and  adnexa  and  also  gives  a  more  permanent  forward  fastening.  The 
field  of  either  of  these  operations  is  very  limited,  for  most  of  the  eases  in  which 
they  are  efficient  may  be  satisfactorily  treated  with  pessaries.  When  there  is  so 
much  disturbance  that  a  pessary  is  not  satisfactory,  there  is  usually  some  intra- 
abdominal condition  that  can  be  more  satisfactorily  handled  by  abdominal  section 
which  permits  thorough  exploration  and  direct  treatment. 

In  those  cases  in  which  abdominal  section  is  required,  there  comes  the  ques- 
tion as  to  which  is  the  preferable  method  of  fastening  the  uterus  forward  after  the 
abdomen  is  open.  The  answer,  to  this  depends  on  the  conditions  within  the  pelvis. 
These  conditions  vary  widely  in  different  cases  of  retrodisplacement,  and  in 
order  to  handle  the  cases  intelligently  they  must  be  grouped  into  classes  repre- 
senting the  principal  pathologic  conditions.  Then,  for  each  class,  that  operation 
should  be  selected  which  best  meets  the  requirements  of  that  class. 

This  definite  classification  of  the  cases  of  retrodisplacement,  with  a  clear 
comprehension  of  the  obstacle  to  be  overcome  in  each  class,  is  a  very  important 
matter  and  one  that  must  receive  much  additional  study  before  the  subject  is 
thoroughly  understood. 

The  matter  of  classification  and  the  adaptation  of  the  operative  measures  to 
the  special  conditions  present  in  these  different  classes,  is  presented  at  some  length 
in  an  article  by  the  author.* 


'The  Preferable  Method  of  Anterior  Fixation  of  the  Uterus  When  the  Abdomen  is  Open.  The 
President's  Address,  St.  Louis  Obstetrical  and  Gynecological  Society,  H.  S.  Crossen,  M.D.  Journal  of 
American  Medical  Association,  May  4,    1907. 


692 


DISPLACEMENT   OF    THE    UTERUS 


In  respect  to  the  conditions  present  in  the  pelvis,  the  cases  may  be  divided 
into  four  classes,  as  follows : 

1.  Those  in  which  the  round  ligaments  and  adjacent  tissues  are  freely 
movable. . 

2.  Those  in  which  the  round  ligaments  and  adjacent  tissues  are  fixed  by 
inflammatory  infiltration  or  other  condition. 

3.  Those  in  which  the  cervix  lies  so  far  forward  that  the  axis  of  the  uterus 
still  lacks  the  normal  anterior  direction  even  when  the  fundus  is  brought  into 
the  front  part  of  the  pelvis. 

4.  Those  in  which  there  is  so  much  inflammatory  infiltration  and  contraction 
of  the  posterior  part  of  the  broad  ligaments,  that  the  uterus  can  not  be  brought 
entirely  forward,  without  danger  of  serious  injury  to  important  structures. 

In  each  class  the  particular  operative  measure  best  suited  to  that  class  must 


Fig.  590.  The  Puncturing  Tenaculum  Forceps.  The  instrument  is  strongly  made  and  slender,  and 
is  designed  to  pass  easily  through  the  tissues  of  the  abdominal  wall,  to  penetrate  the  aponeurosis  and  peri- 
toneum at  any  desired  point,  to  grasp  the  round  ligament  firmly  without  bruising  it,  and  to  return  through 
the  wall,  bringing  the  ligament  along  the  new  canal.      (Crossen — Journal  of  American  Medical  Association.) 

be  chosen.  The  preferable  operative  measures  for  each  of  the  various  classes  is 
discussed  in  the  article  previously  mentioned.  From  this  same  article  the  follow- 
ing description  of  the  operation  most  useful  in  the  cases  of  the  first  class  is 
quoted.  It  is  the  Gilliam-Crossen  operation  mentioned  in  the  preceding  classi- 
fication of  operative  measures. 

"1.  The  special  work  for  which  the  abdominal  cavity  was  opened  lia\'ing 
been  completed,  the  left  round  ligament  is  grasped  with  an  ordinary  tenaculum 
forceps,  about  l^/o  inches  from  the  uterus.  The  right  ligament  is  caught  in  a 
similar  manner  with  another  forceps,  and  then  any  retractors  that  are  in  the 
way  are  removed  from  the  abdominal  wall.  The  grasping  of  the  ligament  of  each 
side  with  the  tenaculum  forceps  facilitates  the  subsequent  manipulation  of  the 
ligaments,  after  the  removal  of  the  retractors  which  expose  the  pelvic  cavity. 

"2.  The  point  of  the  puncturing  tenaculum  forceps  (Fig.  593)  is  entered  in 


OPERATIVE    TREATMENT    OF    RETRODISPLACEMENT  693 

the  left  side  of  the  wound,  just  beneath  the  upper  sheath  of  the  rectus  muscle  and 
about  one  inch  above  the  pubic  bone.  It  is  passed  outward  just  beneath  the 
sheath  for  an  inch  and  then  the  point  is  directed  downward  and  made  to  puncture 
the  rectus  muscle  and  posterior  sheath,  but  not  the  peritoneum.  Guided  by  the 
fingers  in  the  abdomen,  it  is  then  passed  outward  between  the  peritoneum  and  the 
aponeurosis  to  a  point  about  one  inch  from  the  internal  inguinal  ring,  where 
it  is  made  to  penetrate  the  peritoneum. 


Fig.  591.  The  Puncturing  tenaculum  forceps  Introduced  Through  the  Wall,  as  described,  and  grasp- 
ing the  round  ligament.  In  introducing  the  forceps  through  the  wall,  the  point  is  carried  along  the  course 
indicated  by  the  dotted  line  a  to  b  in  the  small  sketch  in  the  corner.  Notice  that  the  puncture  through 
the  strong  musculo-aponeurotic  wall  is  made  at  the  rectus  muscle,  while  the  puncture  through  the  peritoneum 
is  made  at  h,  which  is  near  the  internal  inguinal  ring.  The  distance  from  b  to  the  internal  ring  is  so 
short  (about  one  inch)  that  no  puckering  suture  is  necessary.  This  point  is  further  explained  in  Fig.  592. 
(Crossen- — Journal   of  American   Medical  Association.) 

' '  The  handle  of  the  instrument  is  then  raised  so  as  to  direct  the  point  toward 
the  round  ligament,  and  it  is  made  to  grasp  the  ligament  and  overlying  perito- 
neum about  114  inches  from  the  uterus  (Fig.  591). 

"In  the  class  of  cases  under  consideration,  the  ligament  and  peritoneum  are 
usually  so  stretched  and  lax  that  they  are  easily  drawn  into  the  new  canal  as  a 
small  cord.    If  the  ligament  is  unusually  thick  or  if  the  peritoneum  is  so  thick- 


694 


DISPLACEMENT    OF    THE    UTERUS 


ened  that  it  probably  will  not  pass  easily  into  the  forceps  canal,  a  window  may 
be  snipped  in  the  peritoneum  in  front  of  the  ligament  and  the  ligament  alone 
grasped  and  brought  into  the  canal. 

"3.  The  forceps  is  then  withdrawn,  bringing  the  ligament  with  it  into  the 
forceps-track  and  out  at  the  abdominal  wound  (Fig.  592).    The  loop  of  ligament 


Fig.  592.  The  Left  Round  Ligament  Drawn  into  Place.  Xotice  that  the  direction  of  -the  pull  on 
the  uterus  is  changed  from  lateral  to  anterior.  At  the  same  time  there  is  no  large  opening  between  ihe 
distal  portion  of  the  round  ligament  and  the  anterior  abdominal  wall  requiring  a  suture,  as  in  the  regular 
Gilliam-Ferguson  operation.  The  distance  from  the  peritoneal  exit  of  the  new  ligament  to  the  lateral 
edge  of  the  peritoneal  cavity  at  this  level  is  so  small  (represented  in  the  corner  sketch  in  Fig.  591  by  the 
distance  from  b  to  the  internal  inguinal  ring)  that  it  is  closed  by  moderate  traction  on  the  distal  portion 
of  the  round  ligament  loop  appearing  in  the  wound.  If  it  is  desired  to  bring  the  uterus  farther  forward 
the  proximal  portion  of  the  ligament  is  pulled  on.  If  the  peritoneum  becomes  tense  before  there  is  sufficient 
tension  on  the  round  ligament  to  bring  the  uterus  well  forward,  the  peritoneum  over  the  ligament  loop  may 
be  incised  and  the  ligament  itself  grasped  and  drawn  out  as  desired.  (Crossen — Journal  of  American  Medi- 
cal Association.) 


brought  out  is  now  caught  and  held  by  an  ordinary  tenaculum  forceps,  while  the 
right  ligament  is  brought  out  in  a  similar  manner  with  the  puncturing  tenac- 
ulum forceps.  After  the  ligaments  are  brought  into  position  the  tension  is 
adjusted.  It  may  be  necessary  to  bring  out  a  little  more  of  the  proximal  portion 
or  a  little  more  of  the  distal  portion,  the  former  to  bring  the  fundus  well  forward 
and  the  latter  to  close  effectivelj^  any  space  that  may  exist  between  the  distal 


OPERATIVE    TREATMENT   OF   RETRODISPLACEMENT 


695 


portion  and  the  parietal  peritoneum.  By  paying  attention  to  this  latter  point, 
the  peritoneal  puncture  may  be  made  a  considerable  distance  from  the  internal 
inguinal  ring  without  leaving  any  opening  through  which  an  intestinal  coil  might 
slip.  If  doubtful  on  this  point,  the  forceps  may  be  carried  to  within  half  an  inch 
of  the  ring  or  even  practically  to  the  ring  before  puncturing.  The  peritoneum, 
being  freely  movable  on  account  of  the  loose  subperitoneal  tissue,  is  drawn  in- 
ward and  puckered  when  the  proximal  portion  of  the  ligament  is  drawn  tense  to 
bring  the  uterus  forward.    This  brings  the  peritoneal  exit  near  the  aponeurotic 


Fig.  593.  The  Use  of  the  Puncturing  Tenaculum  Forceps  in  the  regular  Gilliam-Ferguson  Operation. 
The  puncture  is  made  directly  through  the  upper  sheath,  the  rectus  muscle,  the  lower  sheath  and  the 
peritoneum,  and  the  ligament  is  grasped  and  brought  out — the  puckering  suture  having  been  previously- 
passed.  After  the  ligament  is  brought  out  as  desired,  the  puckering  suture  is  tied,  thus  closing  the  opening 
at  the  side  between  the  distal  portion  of  the  round  ligament  and  the  anterior  abdominal  wall.  (Crossen — 
Journal  of  American  Medical  Association.) 


exit  of  the  new  ligament,  beneath  the  rectus  muscle.  The  direction  of  the  new 
ligament  therefore  is  forward,  practically  the  same  as  in  the  Gilliam  operation. 
"4.  The  ligaments  are  then  fastened  in  their  new  position.  If  long  enough, 
the  loops  are  overlapped  in  the  median  line  and  fastened  to  each  other  and  to  the 
upper  sheath  of  the  rectus.  If  not  long  enough  to  reach  to  the  median  line,  they 
are  fastened  securely  in  the  forceps-track  by  catgut  sutures  passed  through  the 


696  DISPLACEMENT   OF    THE   UTERUS 

upper  sheath  and  the  ligaments  beneath.  The  abdominal  incision  is  then  closed 
in  the  usual  way. 

By  the  method  just  detailed,  the  ligaments  may  be  transplanted  into  the 
abdominal  wall  very  quickly — giving  a  strong  reliable  forward  and  upward 
traction  to  the  uterus  and  adnexa  and  without  any  free  bands  or  dangerous 
adventitious  openings.  The  advantages  of  this  particular  technic  in  suitable  cases 
over  the  usual  technic  of  the  Gilliam-Ferguson  operation  are  that  it  simplifies  and 
expedites  the  work  by  doing  away  with  the  temporary  ligation  of  the  ligaments 
and  also  with  the  lateral  puckering  suture. 

The  puncturing  tenaculum  forceps  here  mentioned  may  be  used  also  with 
advantage  in  the  regular  Gilliam-Ferguson  operation  (Fig.  593).  It  may  be 
used  also  in  those  operations  in  which  the  puncture  of  the  aponeurotic  wall  is 
made  practically  at  the  internal  inguinal  ring,  though  care  must  be  exercised 
that  the  deep  epigastric  vessels  be  not  injured. ' ' 

The  author  designed  this  puncturing  tenaculum  forceps  some  time  ago 
and  after  considerable  experimenting  arrived  at  the  present  form.  Using  it 
now  for  several  years  he  has  found  it  so  convenient  and  satisfactory  that  it 
seems  worthy  of  presentation  as  a  useful  addition  to  our  armamentarium. 

The  author  used  it  both  with  the  ordinary  longitudinal  incision  and  with 
the  transverse  incision.  It  is  strong  and  slender  and  is  designed  to  pass  easily 
through  the  tissues  of  the  abdominal  wall,  to  penetrate  the  aponeurosis  and 
peritoneum  at  any  desired  point,  to  grasp  the  round  ligament  firmly  without 
bruising  it  and  to  return  through  the  wall,  bringing  the  ligament  along  the  new 
canal.  Possibly  some  one  has  already  described  such  a  forceps;  if  so,  it  has 
escaped  the  author's  notice.  Both  the  Gilliam  forceps  and  the  Barrett  for- 
ceps are  radically  different. 

PROLAPSE  OF  THE  UTERUS 

Prolapse  of  the  uterus  is  that  condition  in  which  the  uterus  sinks  decidedly 
below  its  normal  level  in  the  pelvis.  It  is  known  also  as  ^ '  procidentia  uteri ' '  and 
is  frequently  referred  to  by  the  patient  as  ' '  falling  of  the  womb. ' ' 

Etiology  and  Pathology 

The  causes  of  prolapse  are  practically  the  same  as  those  of  retrodisplace- 
ment  (see  page  671).  In  fact,  a  slight  prolapse  is  usually  the  first  step  in 
retrodisplacement. 

The  uterus  normally  has  considerable  up  and  down  movement.  Respi- 
ration causes  movement  of  the  uterus,  which  is  noticeable  during  the  speculum 
examination,  especially  with  the  patient  in  the  Sims  posture. 

There  may  be  considerable  exaggeration  of  the  usual  downward  displace- 
ment without  any  symptoms,  and  that  could  hardly  be  called  pathologic.  The 
condition  is  not  called  prolapse  unless  there  is  marked  downward  displace- 


PROLAPSE    OF    THE   UTERUS  697 

ment,  and  this  is  almost  always  accompanied  with  backward  displacement  of 
the  uterus. 

If  the  cervix  is  still  well  within  the  vagina,  the  condition  is  designated 
as  prolapse  of  the  first  degree.  If  the  cervix  protrudes  from  the  vaginal 
orifice  it  is  called  the  second  degree.  If  the  uterus  lies  outside  the  pelvis 
it  is  called  the  third  degree,  or  complete  prolapse.  See  Figs.  268,  269,  270, 
271,  272,  273,  274,  275,  276,  and  277. 

In  the  usual  case  of  prolapse,  the  uterus  is  found  retrodisplaced  and  low 
in  the  pelvis,  the  pelvic  floor  is  found  lacerated  and  there  is  present  more  or 
less  endometritis  with  discharge.  The  vaginal  walls  also  are  relaxed  and 
thrown  into  folds  by  the  position  of  the  uterus,  and  may  be  found  projecting 
outward  at  the  vaginal  opening,  forming  an  anterior  or  posterior  colpoeele. 

The  projecting  vaginal  wall  precedes  the  cervix  on  its  downward  jour- 
ney. If  the  bladder  follows  the  projecting  vaginal  wall,  as  it  frequently  does 
in  severe  prolapse,  the  condition  is  known  as  cystocele  (Figs.  272,  273).  In 
some  cases  of  severe  prolapse,  the  anterior  rectal  wall  follows  the  projecting 
posterior  vaginal  wall,  forming  rectocele. 

The  cervix  in  many  cases  has  been  severely  lacerated  and  is  chronically 
inflamed  and  is  the  seat  of  cystic  disease  and  of  irritating  discharge.  In  severe 
prolapse,  ulcers  often  appear  on  the  cervix  or  vaginal  walls,  being  due  to  irri- 
tation of  the  clothing  and  to  interference  with  the  circulation  of  the  prolapsed 
portion.  The  interference  with  the  circulation  may  be  due  to  two  factors — 
constriction  of  the  prolapsed  portion  by  the  vaginal  opening  and  stretching 
of  the  uterine  blood  vessels  with  consequent  diminution  in  their  caliber.  All 
the  ligaments  of  the  uterus  are  stretched  until  they  give  practically  no  sup- 
port, and  the  lower  pelvis  is  occupied  by  the  intestines  instead  of  by  the  pel- 
vic organs.  Sometimes  coils  of  intestines  may  lie  in  the  cul-de-sac  back  of  the 
uterus,  outside  the  vaginal  opening. 

Symptoms 

The  symptoms  of  prolapse  of  the  uterus  are  dragging  pains  in  the  back 
and  pelvis,  worse  when  walking,"some  protrusion  at  the  vulva'and  sometimes 
difficulty  in  urinating.  In  some  cases  the  protruding  bladder  must  be  pushed 
back  into  the  pelvis  before  the  patient  can  urinate.  Even  then  there  is  more 
or  less  residual  urine  which  is  likely  to  lead  to  cystitis.  Some  patients  com- 
plain of  partial  incontinence  of  urine  when  coughing  or  laughing.  In  excep- 
tional eases,  it  is  this  partial  incontinence  that  brings  the  patient  to  a  physician, 
and  he  must  recognize  the  cause  or  he  will  fail  in  the  treatment. 

Examination  reveals  as  follows  in  the  different  degrees  of  prolapse : 
First  Degree.    The  pelvic  floor  is  relaxed  and  there  is  more  or  less  protru- 
sion of  the  vaginal  walls.    The  uterus  is  usually  retroverted  and  the  cervix  is 
low  in  the  pelvis  and  far  forward,  near  the  vaginal  opening.     Coughing  or 
straining  causes  the  cervix  to  sink  lower  and  the  vaginal  walls  to  protrude  more. 


698 


DISPLACEMENT    OF    THE   UTEEUS 


If  there  is  still  doubt  as  to  whether  the  uterus  sinks  low  enough  to  be 
called  prolapse  or  to  causer  symptoms,  the  patient  may  be  examined  in  the 
standing  posture  (see  page  81),  but  this  is  rarely  necessary. 

Second  Degree.  The  cervix  is  found  presenting  at  the  vulva  (Fig.  269) 
and  may  be  made  to  protrude  by  bearing  down  (Fig.  270).  There  is  also  pro- 
trusion of  the  vaginal  walls  and  sometimes  of  the  bladder. 

The  cervix  and  vaginal  walls  may  return  into  the  pelvis  when  the  pa- 
tient is  lying  down.  There  is  more  or  less  erosion  about  the  cervix  and 
sometimes  ulceration. 

Third  Degree.  There  is  a  mass  nearly  as  large  as  the  fist  protruding 
from  the  vulva  and  lying  between  the  thighs   (Fig.  271).     It  is  covered  by 


Pig.  594.     Fibromyoma    of   the   uterus,   showing   the 
essential   structures. 


Fig.  595.  Myoma  showing  typical  glands — an 
adenomyoma.  The  specimen  consisted  of  a  very 
small  subperitoneal  nodule  which  was  clipped  off. 
without  disturbing  the  uterus  itself,  in  the  course 
of  an  abdominal   operation. 


the  turned  out  vaginal  wall  which,  from  friction  of  the  clothing,  has  become 
■dry  and  hard  resembling  ordinary  epidermis.  At  the  lower  part  of  the  mass 
is  the  cervix,  which  is  represented  by  a  hard  nodule  with  an  opening  in  the 
center  and  more  or  less  erosion  or  ulceration  about  it.  The  appearance  of 
the  cervix  depends  upon  how  much  laceration  of  the  cervix  there  has  been. 

Grasping  the  mass  and  palpating  it  to  determine  its  contents,  there  is 
found  a  hard  elongated  mass— extending  upward  from  the  cervix.  Usually 
the  size  and  shape  of  the  uterus  can  be  accurately  made  out.  From  the  cer- 
-vix  there  is  more  or  less  discharge  which  may  be  clear  and  glairy,  resembling 
the  white  of  an  egg,  or  it  may  be  muco-purulent. 

If  the  bladder  has  prolapsed  also,  it  is  felt  as  a  thick  cushion  of  soft 


PROLAPSE   OF    THE   UTERUS  699 

tissue  in  front  of  the  hard  uterus  (Fig.  273).  To  determine  just  how  much 
the  bladder  is  displaced,  a  sound  may  be  introduced  into  it  and  the  outline 
of  the  cavity  thus  determined  (Fig.  274).  The  vaginal  wall  often  presents 
spots  of  ulceration,  especially  about  the  cervix  (Fig.  271),  and  there  is  often 
much  irritation  over  the  M^hole  prolapsed  mass  and  about  the  external  geni- 
tals. 

Diagnosis 

The  diseases  from  which  prolapse  must  be  differentiated  are  as  follows: 

1.  Hypertrophy  of  Cervix.  In  this  condition,  the  body  of  the  uterus  is 
felt  nearly  at  its  normal  height  in  the  pelvis.  Also  the  depth  of  the  uterus 
is  increased,  the  amount  of  increase  depending  on  the  length  of  the  hyper- 
trophied  cervix.  Furthermore,  the  posterior  vaginal  wall  is  usually  not 
pushed  down,  as  it  would  be  by  a  prolapse  of  the  uterus,  and  the  bladder  is 
usually  not  involved  in  the  projecting  mass.  See  Figs.  279,  280,  281,  282, 
and  283. 

2.  Tumor  or  Cyst  of  Vagina.  Anything  that  causes  the  vaginal  walls  to 
swell  over  a  limited  area  and  protrude,  may  be  mistaken  for  prolapse  of  the 
uterus,  for  example,  vaginal  cyst,  vaginal  hernia,  or  tumor  of  vaginal  wall. 
In  all  these  conditions,  by  careful  digital  examination,  the  cervix  may  be  felt 
above  the  projecting  mass  and  near  its  normal  position.  See  Figs.  287,  288, 
307,  308. 

3.  Tumors  of  Uterus,  Projecting  From  Cervix.  Such  tumors  are,  of  course, 
more  or  less  pediculated  and  almost  invariably  they  are  fibroids.  In  such 
cases,  there  is  felt  near  the  vaginal  entrance,  a  mass,  which  may  be  hard  or 
soft.  If  the  mass  is  sloughing,  part  of  it  will  be  soft.  No  cervical  open- 
ing can  be  felt  in  the  mass  and,  by  exploring  higher  around  the  mass,  the 
cervical  ring  can  be  felt  at  the  upper  part  of  the  vagina.  If  the  tumor  is 
sloughing,  there  is  usually  bleeding  and  a  very  offensive  discharge.  Fur- 
thermore, by  bimanual  examination,  the  body  of  the  uterus  may  be  felt  near 
its  normal  position.     See  Figs.  284,  288,  289,  290,  291,  292,  and  306. 

4.  Inversion  of  Uterus.  In  a  case  of  inversion,  a  large  mass,  apparently 
a  tumor,  is  felt  in  the  vagina.  The  vaginal  walls  can  be  felt  extending  up 
past  the  mass.  If  it  is  sloughing,  there  will  be  bleeding  and  a  foul  dis- 
charge. Furthermore,  the  body  of  the  uterus  is  not  felt  where  it  ought  to 
be  (Fig.  303).  It  is  apparently  nowhere  in  the  pelvis,  and  by  deep  biman- 
ual examination  a  depression  may  be  felt  with  the  abdominal  hand  at  the 
upper  end  of  the  vagina — a  cup-shaped  depression  with  a  hard  margin,  where 
the  body  of  the  uterus  should  be  (Fig.  304).  Inversion  differs  from  a  tu- 
mor, in  that  a  sound  can  not  be  introduced  far  into  the  uterus,  for  the  cav- 
ity is  more  or  less  obliterated  (Fig.  305).  See  also  Figs.  285,  295,  296  to 
302,  306. 


700  DISPLACEMENT    OF    THE    UTERUS 

Treatment 

The  means  of  treatment  mav  be  divided  into  t^vo  classes — palliatiA'e  and 
curative. 

Palliative  Measures 

The  palliative  measures  make  the  patient  more  comfortable,  by  reliev- 
ing the  irritation  which  causes  the  ulceration  and  by  diminishing  the  drag- 
ging on  the  uterine  supports. 

1.  Treatment  of  the  Ulceration  and  Erosion,  and  Reduction  of  the  Mass. 
All  secretion  should  be  cleansed  from  the  extruded  mass  and  from  the  ad- 
jacent surfaces.  Areas  of  ulceration  or  erosion  should  be  touched  with  some 
astringent  silver  preparation  or  with  10%  copper  sulphate  solution,  and  dusted 
with  an  antiseptic-astringent  powder. 

The  mass  should  then  be  anointed  with  an  antiseptic  ointment  and  re- 
duced within  the  pelvis.  By  bimanual  manipulation,  the  backward  displace- 
ment should  be  corrected  so  far  as  possible,  the  fundus  being  brought  for- 
ward and  the  cervix  pushed  far  back  in  the  pelvis. 

2.  Pessaries.  The  next  step  is  to  hold  the  uterus  in  the  pelvis  as  near  its 
normal  position  as  possible.  If  there  is  enough  left  of  the  pelvic  floor  to  hold 
a  pessary,  that  should  be  tried. 

The  style  of  pessary  preferred  in  suitable  cases  is  that  used  for  retrodis- 
placement  (Fig.  428),  for  the  object  is  to  keep  the  fundus  uteri  in  the  forward 
position.  As  long  as  the  fundus  is  forward  and  the  cervix  well  back  in  the 
pelvis,  the  organ  can  hardly  prolapse,  at  least  not  to  the  extent  of  coming  out- 
side. This  form  of  pessary  is  effective  only  in  cases  of  slight  prolapse.  In 
cases  of  marked  prolapse,  the  above  mentioned  pessary  fails,  because  the  pel- 
vie  floor  has  been  too  much  stretched  to  hold  the  pessary  in  place.  The  an- 
terior end  of  the  pessary  slips  do%^ni  to  the  wide  part  of  the  pubic  arch  and 
slips  out  of  the  dilated  vaginal  opening.  In  such  a  case  the  inflated  ring  pes- 
sary (Fig.  436)  will  sometimes  hold  the  uterus  within  the  pelvis.  The  Menge 
pessary  (Fig.  437)  is  sometimes  effective  where  those  above  mentioned  fail. 

The  most  generally  satisfactory  pessary  for  severe  prolapse  is  the  CtcIi- 
rung  pessary  (see  page  387  and  Figs.  340,  341,  342),  when  one  knows  how 
to  use  it.  The  author  has  found  it  so  effective  that  for  several  j'ears  he  has 
used  it  to  the  practical  exclusion  of  other  pessaries  in  those  cases  of  severe 
prolapse  which  can  not  be  subjected  to  operation. 

In  those  rare  cases  in  which  none  of  the  above  pessaries  will  keep  the 
uterus  within  the  pelvis,  and  the  patient  refuses  curative  operative  measures, 
the  cup  and  belt  pessary  may  be  used.  In  some  cases  this  makes  the  patient 
fairly  comfortable,  and  with  proper  care  may  be  worn  indefinitely.  In  other 
cases  it  causes  so  much  distress,  by  pressure  on  the  vaginal  walls  or  cervix  or 
other  pelvic  structures  or  by  irritation  from  the  abdominal  or  perineal  bands 
that  the  patient  abandons  it  after  a  trial. 


TREATMENT    OF   PROLAPSE   OF    THE    UTERUS  701 

3.  Tampons,  Rest  in  Bed,  Astringent  Douches.  Where  no  form  of  pessary 
will  hold  the  structures  back,  a  firm  vaginal  packing  of  gauze  or  cotton 
tampons  may  be  placed,  preferably  with  the  patient  in  the  knee-chest  pos- 
ture or  in  Sims'  posture.  This  packing  will  hold  the  uterus  up  temporarily 
and,  by  placing  a  pad  over  the  vulva  and  holding  it  firmly  in  place  by  a 
strong  T-bandage,  the  packing  may  be  kept  in  place  two  days.  This  method 
is  very  useful  when  treating  the  ulceration  often  found  about  the  cervix  and 
also  to  give  temporary  relief  while  preparing  the  patient  for  operation. 

If  the  patient  can  spare  the  time  to  go  to  bed  and  remain  there  a  week  or 
two,  taking  astringent  douches  when  not  packed,  she  will  experience  con- 
siderable relief  from  pain  and  discomfort.  This  is  especially  important  when 
there  is  ulceration  of  the  cervix  or  vagina  requiring  treatment. 

Curative  Measures 

These  are  all  operative  and  may  be  divided  into  two  classes — (a)  those 
that  preserve  all  the  genital  functions  and  (b)  those  that  do  not. 

A.  Genital  Functions  Preserved.  The  uterus  and  adjacent  structures  are 
restored  to  approximately  normal  position  and  all  the  genital  functions  are 
preserved. 

1.  Fastening  of  Fundus  Uteri  Forward  and  Upward,  and  Repair  of 
Pelvic  Floor,  The  body  of  the  uterus  is  brought  forward  and  elevated  and  the 
fundus  as  fastened  in  the  desired  position  by  one  of  the  methods  detailed 
under  retrodisplacements.  The  pelvic  floor  is  thoroughly  repaired  by  one 
of  the  methods  detailed  in  Chapter  v.  A  curetment  is  usually  combined  with 
the  above  measures  to  reduce  the  weight  of  the  uterus,  and  if  the  cervix  is 
sufiiciently  enlarged  or  elongated,  a  part  of  it  is  amputated   (see  Chapter  vi). 

All  this  may  be  done  during  one  anesthesia  or  it  may  be  divided  into  two 
operations  sonie  weeks  apart,  as  thought  best  in  the  particular  case.  These 
measures  are  carried  out  in  such  a  way  that  the  function  of  pregnancy  and 
parturition  is  not  interfered  with.  In  fact,  the  chance  of  pregnancy  is  in- 
creased by  the  restoration  of  the  uterus  to  its  normal  position. 

Practically  all  cases  of  prolapse  in  the  child-bearing  period  can  be  treated 
satisfactorily  in  this  way,  where  the  form  of  operation  best  adapted  to  the 
particular  case  is  selected  and  the  proper  technic  employed.  There  are  ex- 
ceptional cases,  but  they  are  very  rare. 

2.  Bringing  a  Strong  Portion  of  the  Lower  Part  of  Each  Broad  Liga- 
ment in  Front  of  the  Cervix  Uteri  and  Fastening  it  There.  This  is  accom- 
plished through  an  incision  in  the  anterior  vaginal  vault.  It  promises  much 
in  these  cases,  especially  when  combined  with  shortening  of  the  sacro-uter- 
ine  ligaments  and  operation  for  cystocele  and  repair  of  the  pelvic  floor.  It 
has  not  yet  been  long  enough  in  use  to  demonstrate  certainly  how  well  the 
shortened  broad  ligaments  will  stand  the  strain. 


702  DISPLACEMENT   OF    THE   UTERUS 

B.  Genital  Functions  Sacrificed.  The  uterus  is  removed  or  partly  removed 
or  so  placed  that  pregnancy  would  be  dangerous.  These  measures  are,  of 
course,  applicable  only  to  patients  past  the  menopause  or  in  the  menopause, 
or  in  whom  for  some  reason  pregnancy  can  not  again  occur. 

1.  Utilization  of  the  Uterus  to  Overcome  Prolapse  of  Bladder  and 
Vaginal  Walls  (Freund,  Fritsch,  Watkins,  Wertheim.)  Through  an  incision  in 
the  anterior  vaginal  wall,  the  bladder  is  separated  from  the  vagina  and 
uterus,  and  pushed  up.  Then  the  fundus  uteri  is  brought  forward  beneath 
the  bladder  and  fastened  securely  to  the  anterior  vaginal  wall.  The  redun- 
dant portion  of  the  anterior  vaginal  Avail  is  cut  away.  The  sutures  extend 
deeply  at  the  sides  so  as  to  unite  the  firm  lateral  tissues  to  the  uterus  and 
thus  give  good  support  to  the  bladder  and  other  structures  above.  This, 
at  the  same  time,  turns  the  cervix  into  the  posterior  part  of  the  pelvis  and 
puts  the  vaginal  walls  on  the  stretch  and  prevents  their  prolapse.  This  is 
combined  Math  a  strong  repair  of  the  pelvic  floor.  The  special  steps  and  the 
various  modifications,  it  will  not  be  necessary  to  detail  here. 

This  operation  has  several  advantages  over  hysterectomy  and,  if  the  re- 
sults eventually  prove  lasting  and  satisfactory,  will  probably  largely  replace 
it  as  a  cure  for  prolapse. 

2.  Hysterectomy,  Either  Vaginal  or  Abdominal,  with  High  Fixation 
of  the  Vaginal  Stump,  and  followed  by  repair  of  the  pelvic  floor  either  at  the 
same  sitting  or  later. 

Particular  attention  must  be  called  to  the  fact  that  hysterectomy  fails, 
in  many  cases  to  cure  the  prolapse  of  pelvic  structures  unless  particular  care 
is  taken  to  fasten  the  vaginal  stump  very  high.  Without  this  precaution, 
the  vagina  is  liable  to  prolapse  again.  The  intestines  and  bladder  also  come 
down  and  the  last  state  of  the  patient  is  worse  than  the  flrst.  This  defect 
of  the  old  vaginal  hysterectomy  for  prolapse  the  author  pointed  out  and 
illustrated  by  cases  that  came  to  him  from  other  operators,  some  years  ago,, 
when  that  operation  was  at  its  height  as  a  cure  for  this  affection.* 

Hysterectomy  as  mentioned  above,  however,  with  high  fixation  of  the 
vaginal  stump  (to  the  broad  ligament  stumps  or  to  the  anterior  abdominal 
wall),  is  a  different  proposition  and  is  effective  in  relieving  the  distressing 
symptoms. 

OTHER  DISPLACEMENTS  OF  UTERUS 

Anteflexion  of  the  Cervix  Uteri.  In  this  affection  the  cervix  uteri  is  bent 
forward  so  that  the  axis  of  the  cervix  is  directed  along  the  vaginal  canal  in- 
stead of  across  it.  The  axis  of  the  cervix  forms  a  sharp  angle  with  that  of 
the  corpus  uteri,  the  point  of  bending  being  at  the  internal  os. 


*Vaginal  Hysterectomy  for  Prolapsus,  H.   S.   Crossen,  M.D.,   Western  Medical  and  Surgical  Gazette, 
1898. 


TREATMExNTT    OF    PROLAPSE    OF    THE    UTERUS  703 

Anteflexion  of  the  cervix  uteri  is  nearly  always  a  developmental  defect, 
due  to  the  persistence  of  the  fetal  position  of  the  cervix  uteri,  as  explained 
when  considering  the  anatomy  of  the  uterus  at  different  periods  of  life  (see 
Chapter  vi. 

Almost  the  only  symptom  of  anteflexion  of  the  cervix  is  dysmenorrhea, 
and,  therefore,  it  seems  best  to  consider  the  subject  in  detail  in  Chapter  xiv, 
under  the  "neurotrophic"  form  of  dj'smenorrhea. 

Anteflexion  of  the  Corpus  Uteri,  Anteversion  of  the  Corpus  Uteri  and 
Lateral  Displacements  of  the  Uterus  can  hardly  be  classed  as  diseases.  They 
occur  only  as  symptomatic  disturbances  in  the  course  of  other  diseases,  and 
of  themselves  do  not  give  rise  to  symptoms  nor  require  treatment. 

Inversion  of  the  Uterus.  This  serious  and  rare  displacement  is  an  ob- 
stetric affection.  It  practically  always  occurs  in  the  puerperal  state,  except 
when  due  to  the  dragging  Aveight  of  a  tumor.  When  due  to  a  tumor,  it  simply 
constitutes  one  of  the  pathologic  conditions  incident  to  the  tumor  (Figs.  291, 
306)  and  does  not  require  separate  consideration. 


CHAPTER  VIII 

NON-MALIGNANT  TUMORS  OF  UTERUS 

FIBROMYOMA  OF  THE  UTERUS 

Fibromyoma  of  the  uterus  is  a  tumor  composed  of  fibrous  and  muscular 
tissue.    It  is  called  also  uterine  "fibroid"  and  uterine  ''myoma." 

Etiology 

The  essential  cause  is  not  known.  Some  interesting  theories  have  been 
advanced,  but  they  are  still  theories  only.  The  tumor  is  analogous  to  those 
growths  which  frequently  enlarge  the  prostate  in  the  male.  As  bearing  on 
the  etiology  of  uterine  fibromyomata,  it  may  be  noted  that  they  are  usually 
multiple,  there  being  but  few  exceptions  to  the  rule  that  where  there  is  one 
palpable  fibroid  there  are  many  smaller  nodules.  They  occur  most  frequently  in 
middle  life  (period  of  sexual  activity),  though  they  may  occur  at  any  age. 
Again,  child-bearing  apparently  has  no  influence  in  causing  them.  This  is 
in  marked  contrast  to  carcinoma,  particularly  carcinoma  of  the  cervix,  which 
occurs  almost  exclusively  in  women  who  have  borne  children  or  who  have 
had  some  injury  to  the  cervix. 

Pathology 

1.  Composition.  A  fibromyoma  is  composed  principally  of  connective  tis- 
sue and  involuntary  muscular  tissue — the  same  tissues  that  compose  the  uterine 
wall  (Fig.  594).  In  a  small  proportion  of  fibroids  there  are  found  small  irreg- 
ular cavities  resembling  glands  and  lined  with  epithelium.  Such  tumors  are 
designated  by  the  term  ''adenomyoma"  (Fig.  595). 

2.  Relation  to  Uterine  WaU.  The  fibroid  starts  as  a  small  nodule  in  the 
muscular  layer  of  uterine  wall  (Figs.  335,  336).  As  it  enlarges  there  usually 
develops  a  distinct  capsule,  or  layer  of  condensed  tissue,  which  separates  the 
tumor  proper  from  the  normal  uterine  wall  surrounding  it  (Figs.  596,  597, 
598,  599,  604).  From  this  capsule  it  may  be  easily  shelled  out,  except  when 
there  has  been  inflammatory  infiltration  of  the  capsule  and  tumor.  As  long 
as  the  tumor  is  surrounded  by  the  muscular  tissue  of  the  wall,  it  is  known 
as  an  intramural  or  interstitial  fibroid  (Figs,  596,  600,  601).  They  comprise 
60  to  70  per  cent  of  the  cases. 

704 


FIBEOMYOMA   OF    UTERUS 


705 


^jiss^tr 


Fig.  S96.  Longitudinal  section  through  a  uterus  sheltering 
a  single  interstitial  fibroid  in  the  fundus  portion,  leaving 
uterine    cavity   undisturbed. 


Fig.  597.  Showing  the  Capsule  of  Fibro- 
myoma.  The  layers  of  capsule  have  sep- 
arated   somewhat. 


Fig.  S98.  A  view  of  an  intact  portion  of  the 
capsule  (Fig.  597),  under  higher  power.  Notice 
the  general  longitudinal  direction  of  the  fiber  bun- 
dles due  to  compression. 


Fig.  599.  The  same  capsule,  under  still  higher 
power,  showing  the  general  longitudinal  direction  of 
the  individual  fibers. 


706 


NON-MALIGNANT    TUMORS    OF    UTERUS 


A 


A 


Fig.   600 


Multiple   Fibromyotnata   of  the   uterus.      A.    The   divided   uterine    cavity. 
Uterine  Fibromyomata.) 


(Bishop- 


Fig.  601.  Multiple  Fibromyomata  of  the  Uterus,  sectioned  so  as  to  show  the  relation  of  the  tumor- 
masses  to  the  uterine  wall.  The  encapsulation  of  the  fibroid  nodules  is  well  shown.  To  the  extreme  left  is  a 
subperitoneal  fibroid  (not  sectioned).  The  top  of  the  uterine  cavity  is  seen  near  the  center  of  the  left  half 
of  the  sectioned  mass. 


FIBRO  MYOMA   OF   UTERUS  707 

As  the  ordinary  encapsulated  tumor  grows,  it  pushes  in  the  direction 
of  least  resistance,  stretching  the  muscular  tissue  around  it  and  tending  to 
push  the  muscular  tissue  aside.  "When  it  pushes  aside  the  muscular  tissue  to 
the  outer  side  of  it  and  comes  to  lie  just  beneath  the  peritoneum,  it  is  known 
as  a  subserous  or  subperitoneal  fibroid  (Figs.  375,  613).  They  comprise  20 
to  30  per  cent  of  the  eases. 


Fig.   602.     A  Large  Fibromatous  Uterus  removed  by  abdominal   operation. 

This  process  of  escape  from  the  grasp  of  the  muscular  tissue  may  pro- 
gress, the  tumor  projecting  farther  and  farther  beyond  the  outline  of  the  uterus 
but  still  covered  by  the  peritoneum,  until  it  is  attached  to  the  uterus  only 
by  a  comparatively  narrow  band  of  tissue,  or  pedicle,  carrying  the  blood  ves- 
sels and  covered  by  peritoneum.  It  is  then  a  pediculated  subperitoneal  fibroid 
(Fig.  351). 


708 


NON-MALIGNANT    TUMORS   OF   UTERUS 


Fig.  603.  Uterus  shown  in  Fig.  602  laid  open.  As  compared  with  uterus  shown  in  Fig.  596,  this 
uterus  also  contains  an  interstitial  nodule  in  its  fundus  portion,  but  the  uterine  cavitjf  is  greatly  dilated  and 
distorted. 


Fig.   604. 


Photomicrograph  of  a  small  encapsulated  fibromyoma  located  underneath  the  endometrium,  visible 
at  left  end  of  the  illustration. 


FIBROMYOMA   OF   UTERUS  709 

In  some  cases  adhesions  to  adjacent  structures  are  formed,  and  through 
these  adhesions  the  tumor  may  receive  part  of  its  blood  supply.  Occasion- 
ally the  pedicle  of  such  a  tumor  is  severed  by  torsion  or  otherwise  and  the 
tumor  is  thus  entirely  separated  from  the  uterus  and  receives  its  blood  sup- 
ply through  the  vascular  adhesions.  Such  a  tumor  is  known  as  a  detached 
or  ''parasitic"  or  wandering-  fibroid,  and  constitutes  one  of  the  curiosities  of 
pathology. 

If  a  tumor  which  is  escaping  outward  from  the  grasp  of  the  muscular 
wall  is  so  situated  that  it  projects  into  the  broad  ligament,  it  is  known  as  an 


\>. 


Fig.  60S.     I,arge    Submucous    Fibroid    filling   the    uterine    cavity    and    partially    protruding    into    the    vagina 

through  the  dilated  cervix. 

intraligamentary  fibroid.  If  it  projects  in  such  a  situation  that  it  raises  the 
peritoneum  behind  the  uterus  and  passes  back  of  the  peritoneum,  it  is  then 
called  a  retroperitoneal  fibroid. 

On  the  other  hand,  the  fibroid,  as  it  develops,  may  push  its  way  inward 
instead  of  outward,  and  may  come  in  time  to  lie  beneath  the  endometrium, 
where  it  is  known  as  a  submucous  fibroid  (Figs.  337,  605,  606),  Submucous 
fibroids  comprise  about  10  to  15  per  cent  of  the  cases.  The  proximity  of  the 
growth  to  the  endometrium  causes,  in  the  latter,  changes  due  to  pressure. 


710 


NON-MALIGNANT    TUMORS   OF    UTERUS 


The  glandular  position  is  rarefied,  the  surface  epithelium  flatter  than  usual, 
missing  entirely  in  some  areas  (Fig.  606). 

The  submucous  fibroid  may  project  farther  and  farther  into  the  uterine 
cavity,  until  it  is  attached  to  the  uterine  wall  only  by  a  narrow  pedicle  (pedic- 
ulated  submucous  fibroid — Figs.  288,  289,  607.  A  pediculated  submucous 
fibroid  may  be  forced  out  into  the  vagina  while  still  attached  to  the  uterine 
Avail  (Figs.  289,  605,  607)  and  may  in  this  way  cause  partial  or  complete  in- 
version of  the  uterus  (Figs.  296,  306),  a  fact  that  must  be  kept  in  mind  when 
removing  such  a  growth  by  operation. 

Some  fibroids,  especially  the  adenomata,  are  without  a  distinct  limiting 


Fig.  606.  In  submucous  fibromyoma  the  covering  endometrium  shows  changes  due  to  pressure.  The 
glandular  portion  of  the  mucosa  is  rarefied,  the  covering  epithelium  flattened,  and  entirely  absent  in  some 
places   (upper  end  of  picture). 


capsule.  The  tumor  tissue  blends  directly  with  the  uterine  wall  (Fig.  608). 
Such  a  tumor  is  called  a  diffuse  fibroid.  It  may  occupy  only  a  small  area  or 
may  extend  all  the  way  around  the  uterine  cavity. 

Most  fibroids  are  found  in  the  body  of  the  uterus,  as  indicated  in  the 
various  illustrations. 

In  a  certain  proportion  of  cases  the  fibroid  is  situated  in  the  cervix. 
Bland-Sutton  found  in  a  series  of  500  cases,  that  5%  Avere  cervix  fibroids. 
These  are  moi-e  often  single,  and  rarely  project  into  the  cavity,  as  the  cervi- 
cal cavity  is  small.  They  are  usually  comparatively  small,  but  sometimes 
reach  a  size  of  8  lbs. 

4.  Secondary  Changes.     Under  composition  is  given  the  primary  struc- 


PIBROMYOMA   OF    UTERUS 


711 


■■^-^f^^^^^,    '"w- 


Fig.  607.  Uterus  containing  one  small  interstitial  and  several  subserous  fibroids  and  °"^  ^^""^J^^*^ 
and  distinctly  pedunculated  submucous  fibroid.  Its  lower  end  hangs  in  form  of  a  polypus  mto  ttie  vagi  . 
The  illustration  shows  the  cervical  ring  and  the  upper  portion  of  the  vagina. 


712 


NON-MALIGNANT    TUMORS    OF    UTERUS 


Fig.   608.     A    Diffuse    Adenomyonia    of    the    Uterus.       (Bland-Sutton — Hysterectomy.) 


f 

...\  ♦"'^   ' 

'■■■i'''i- 

•  - 

■    '-  "*''  '  *'. 

t 

*A';-: 

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'"'         1'"' 

;*■ 

*  ^^  -^  - 

c< :. 

't-'^^B 

j^^t.-     » 

^^'  "            ' 

'  f^}l    ', 

V  .    '  * 

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^^^K''  *   "  *    ' 

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Fig.  609.     Hyaline    Degeneration    and 
I<iquefaction    in    a    Fibromyoma. 


Fig.   610.      Same   as   Fig.    609,    under   high   power. 


PIBROMYOMA   OF    UTERUS 


713 


-A* 


Fig.   611.      Cystic  cavity  forming  in  the  largest  of  the  numerous  intramural  nodules  of  a  fibromatous  uterus. 


714 


NON-MALIGNANT    TUMORS   OF    UTERUS 


Fig.  612.     A   Large   Cystic  Fibromyoma.      (Kelb' — Operative    Gynecology.) 


FIBRO  MYOMA    OF    UTERUS 


715 


Pig.   613.     A    large    subperitoneal    fibroid    attached    near    left    uterine    horn.      The    shaded    area    shows    the 
situation  of  the  necrotic  area  within  the  tumor. 


716 


NON-MALIGNANT   TUMORS   OF   UTERUS 


Fig.    614.      Necrosis   of   an   Intraligamentary    Fibromyoma.      (Hirst — Diseases   of    Women.) 


Fig.  615.     Photomicrograph  of  suppurating  fibroid. 


FIBROMYOMA   OF    UTERUS 


717 


Fig.  616.  Section  of  a  Necrotic  Fibroid.  The  author  saw  the  patient  in  consultation  with  Dr.  C.  O.  C. 
Max.  There  was  a  large  fibroid  extending  nearly  to  the  umbilicus,  which  had  become  necrotic  from  infec- 
tion due  to  the  introduction  of  a  uterine  sound  by  a  midwife.  The  patient  was  in  a  desperate  condition. 
The  clinical  features  are  mentioned  briefly  on  page  7-!8.  At  the  operation  it  was  found  that  the  necrotic 
fibroid  had  perforated  the  uterine  wall  and  was  in  contact  with  the  omentum.  This  Antero-posterior  Section 
of  the  removed  Uterus  and  Tumor  shows  accurately  the  relation  of  the  necrotic  mass  to  the  uterine  wall. 
It  was  almost  free  in  its  suppurating  bed.     Fig.  617  shows  the  perforation  through  the  uterine  wall. 


718 


NON-MALIGNANT   TUMORS   OP   UTERUS 


Fig.  617.  A  Necrotic  Fibroid  Perforating  the  Uterine  Wall.  Same  specimen  as  shown  in  Fig.  616. 
The  specimen  consists  of  the  uterus  and  tumor  removed  by  total  hysterectomy.  The  patient  recovered. 
The  Perforation  here  sho^n  was  covered  by  adherent  omentum.  As  soon  as  the  omental  adhesions  were 
separated,  pus  from  the  suppurating  bed  in  which  the  necrotic  mass  lay  poured  into  the  peritoneal  cavity. 
The   tumor  was  large  and   the   perforation  was  at  the  top   of  the   mass,   near   the   umbilicus. 


FIBROMYOMA   OP    UTERUS 


719 


"^^mu;,^^ 


Fig.   618.      Section  through  a  sarcoma  originating  in  a  fibromyoma   of  the   uterus. 


720 


NOX-IilALIGXAXT    TUMORS    OF    UTERUS 


lure  of  the  various  forms  of  libromyoma.  In  many  eases  there  are  found 
secondary  changes  in  tlie  tumor  structure.  These  changes  are  edema,  myxo- 
matous degeneration,  necrobiosis,  necrosis,  suppuration,  cystic  degeneration, 
calcification,  malignant  degeneration  and  other  rarer  changes  (atrophy,  fatty 
degeneration,  amyloid  degeneration).  The  relative  frequency  -with  ^vhieh  the 
more  important  of  these  secondary  changes  has  been  noted  in  operated  cases, 
is  shown  in  the  table  on  page  742.  Necrosis  and  suppuration  are  shown  in 
Figs.  614,  615,  616,  and  617 ;  hyaline  degeneration  with  liquefaction,  in  Figs. 
609  and  610.  Cystic  change  is  shown  in  Figs.  402,  611,  and  612.  Sarcomatous 
development  is  shown  in  Figs.  618,  619,  620  and  621. 

5.  Complications   and   Associated   Diseases.     These   are   very  numerous 
and  very  important,  for  a  large  proportion  of  the  deaths  and  of  the  suffering 


in  fibroid  cases  comes  from  them.  Some  of  these  conditions  are  due  directly  to 
the  fibroid,  some  are  due  indirectly  to  it  and  some  have  no  etiologic  connection 
Avith  the  fibroid,  but  are  only  associated  affections.  Some  of  them  can  not  be 
assigned  exclusively  to  one  group  or  the  other,  therefore,  all  of  them  will  be 
considered  together.  For  convenience  they  are  divided  into  three  classes  ac- 
cording to  locality — (a)  in  the  uterus,  (b)  in  adjacent  structures  and  (c)  in 
distant  organs. 

a.  In  this  class  come  thickening  of  the  endometrium,  distortion  of  the 
uterine  cavity  (Figs.  603  and  607)  and  displacement  of  the  uterus. 

b.  Here  are  found  salpingitis,  hydrosalpinx  and  pyosalpinx.     Also,  com- 
pression of  the  OA'aries,  with  inflammation  and  sometimes  hematoma.     There 


FIBROMYOMA   OF    UTERUS 


721 


Fig.  620.  A  Sarcoma  Developing  in  a  Cervical  Stump.  ,  The  pelvis  is  viewed  from  above.  Rising 
from  the  pelvis  between  the  bladder  and  the  rectum  is  a  smooth  lobulated  growth.  To  the  left  is  the  intact 
and  normal  left  ovary.  The  right  appendages  were  removed  at  the  first  operation.  The  first  operation  was 
supravaginal  hysterectomy  for  Fibromyoma.  The  original  tumor  is  shown  in  Fig.  621.  (Cullen — Jojirval  of 
American  Medical  Association.) 


722 


NON-MALIGNANT    TUMORS   OF    UTERUS 


■/      i 


^l^.'F 


,s.V0t 


»- 


Fig.  621.  The  Fibromyoma  removed  in  the  Supravaginal  Hysterectomy  mentioned  under  Fig.  620. 
After  the  development  of  the  sarcoma  in  the  cervical  stump,  the  original  tumor  (supposedly  a  simple  fibroid) 
was  sectioned  as  here  shown.  Several  large  areas  of  sarcomatous  degeneration  were  found,  the  most  marked 
of  which  are  indicated  by  the  letter  d.      (Cullen — Journal  of  American  Medical  Association.) 


SYMPTOMS   AND    SIGNS    OF   FIBROMYOMA 


723 


may  be  troublesome  pressure  on  the  bladder  or  rectum  or  pelvic  blood  vessels. 
In  some  cases  there  is  marked  displacement  of  the  bladder  (Fig.  622). 

c.  The  changes  in  distant  organs  concern  principally  the  heart  and  the 
kidneys.  These  changes  are  often  serious.  They  are  mentioned  at  some 
length  below,  in  considering  the  dangers  from  long-standing  fibroids  (see 
page  743). 


Fig.  622.  A  Large  Fibromyoma  of  the  Uterus,  which  has  drawn  the  Bladder  far  up  into  the 
abdomen.  Notice  the  immense  veins  on  the  peritoneal  surface  of  the  bladder.  (Kelly — Operative  Gyne- 
cology.) 


SYMPTOMS  AND  SIGNS 


Symptoms 

The  symptoms  given  by  the  patient  are,  in  the  usual  order  of  their  ap- 
pearance, (1)  menorrhagia,  (2)  leucorrhea,  (3)  pressure  symptoms,  (4)  pain 
and  (5)  a  lump  in  the  lower  abdomen. 

1.  Menorrhagia.  This  is  usually  the  first  disturbance  noticed,  partic- 
ularly in  submucous  and  interstitial  growths.  There  is  much  variation  in 
the  menstrual  disturbance.  Usually  the  flow  is  increased,  but  sometimes  it 
is  diminished.  Emmet,  in  a  series  of  216  cases,  found  the  menstrual  flow 
decidedly  increased  in  50  per  cent,  unchanged  in  20  per  cent,  lessened  in  16 
per  cent  and  irregular  in  13  per  cent. 

2.  Leucorrhea  is  usually  present  after  a  time,  especially  in  the  submu- 
cous and  interstitial  growths. 

3.  Pressure  Symptoms.  These  are  indefinite,  simply  an  indication  that 
there  is  some  slight  disturbing  element  in  the  pelvis.  The  patient  has  some 
bladder  irritability  and  a  feeling  of  weight  in  the  pelvis.  There  is  usually 
constipation.  After  the  tumor  becomes  large,  marked  pressure  symptoms  oc^ 
cur. 

4.  Pain.  This  appears  later.  It  is  usuallj^  present  as  a  backache  (lumbar 
or  sacral)  or  as  pain  in  the  lower  abdomen  or  a  thigh-pain  on  one  or  both 


724  NON-MALIGNANT    TUMOES   OF    UTERUS 

sides.     The  pains  usually  come  and  go  at  first,  and  are  worse  when  the  pa- 
tient is  on  her  feet  and  also  at  the  menstrual  periods. 

5.  Lump.  In  a  large  proportion  of  the  cases,  after  some  months  or  years, 
a  lump  is  noticed  in  the  lower  abdomen.  If  the  mass  is  smooth,  however,  it 
is  surprising  how  large  it  will  sometimes  get  before  the  patient  notices  it. 
Of  course  a  mass  with  nodular  projections  is  usually  noticed  as  soon  as  it 
begins  to  distend  the  lower  abdomen.  In  a  certain  proportion  of  cases,  the 
mass  even  when  large  is  still  too  deeply  placed  in  the  pelvis  to  be  appreciable 
to  the  patient,  and  in  some  cases  (small  submucous  fibroid)  the  mass  is  not 
appreciable  to  the  physician,  even  on  careful  bimanual  examination,  though 
there  may  be  much  bleeding  and  distress. 

Examination  Findings 

The  diagnosis  of  uterine  fibroid  must  rest  on  the  examination  findings,  for 
the  symptoms  are  not  distinctive.  Taking  up  the  points  as  given  in  the 
Diagnostic  Table  (pages  327  to  329),  we  find  as  follows  in  the  case  of  a  fibro- 

myoma : 

« 

1.  Position  of  Mass.  In  the  central  part  of  the  pelvis  and  extending  from 
there  toward  one  side. 

2.  Size  of  Mass.  May  be  any  size,  from  one  barely  palpable  in  the  wall 
of  the  uterus  to  a  large  tumor  filling  the  abdomen. 

3.  Shape.  Individual  tumors  are  apparently  spherical,  but  as  they  pro- 
ject from  the  uterus  or  grow  beside  each  other,  they  form  a  mass  of  very  ir- 
regular contour,  usually  presenting  several  distinct  bosses  or  rounded  pro- 
jections outside  the  general  outline  of  the  mass. 

4.  Consistency.  Firm,  usually  much  harder  than  the  adjacent  uterine 
wall.  Occasionally,  part  of  a  tumor  will  undergo  cystic  change — ^but  even 
then  the  greater  part  of  the  mass  is  usually  solid. 

5.  Tenderness.  Not  tender,  unless  incarcerated  in  pelvis  or  pressing  on 
nerves  or  accompanied  Avith  infiammation. 

6.  Mobility.  The  tumor  and  uterus  are  movable  together  up  and  down 
in  the  pelvis,  but  they  are  not  movable  separately  imless  the  fibroid  is  pedic- 
ulated. 

7.  Attachment.  Attached  in  the  uterine  region  and  free  elsewhere,  un- 
less complicated.  A  subperitoneal  fibroid  with  a  long  pedicle  may  be  mis- 
laken  for  a  growth  from  some  of  the  abdominal  organs.  The  pedicle  con- 
necting the  mass  with  the  uterus,  can  usually  be  felt  on  deep  bimanual  pal- 
pation. In  a  difficult  case,  a  useful  expedient  is  to  have  an  assistant  grasp 
the  tumor  and  draw  it  up  into  the  abdomen  while  the  examiner  makes  deep 
bimanual  palpation  in  search  of  the  pedicle,  which  is  thus  made  tense  and  is 
easier  felt  (Fig.  102). 

8.  Apparent  Point  of  Origin.     From  uterus.     Occasionally  a  fibroid  be- 


SYMPTO:\[S   AND    SIGNS    OF   FIBROMYOMA  725 

comes  detached  from  the  uterus  or  has  such  a  long  pedicle  that  it  appears 
free,  but  that  is  rare. 

9.  Relation  to  Uterus.  Intimately  connected  to  the  uterus,  growing  from 
the  same.     May  be  from  any  part,  usually  from  body. 

10.  Position  of  Uterus.  IMay  be  displaced  in  any  direction,  may  be  in 
normal  position. 

11.  Size  of  Uterus.  Enlarged  by  tumor  in  wall,  cavity  lengthened.  But 
do  not  explore  with  sound  unless  necessary. 

12.  Shape  of  Uterus.  Usually  distorted  and  presenting  one  or  more  dis- 
tinct projections.     Occasionally  symmetrically  enlarged. 

13.  Consistency  of  Uterus.  Uterine  tissue  proper  of  normal  consistency, 
but  fibroid  nodules  harder.  Occasionally  a  tumor  will  present  a  softened 
area  (edematous)  or  a  fluctuating  area  (cystic).  Occasionally  the  cervix  is 
softened  by  edema  incidental  to  impaction  in  the  pelvis,  but  there  is  rarely 
enough  softening  to  imitate  pregnancy. 

14.  Tenderness  of  Uterus.  Not  tender  on  palpation  or  movement,  except 
vrhen  complicated. 

15.  Mobility  of  Uterus.  Movable  in  pelvis  with  tumor,  unless  tumor  is 
so  large  as  to  fill  pelvis  or  so  situated  as  to  put  uterine  supports  on  stretch, 
or  complicated  by  pelvic  inflammation  or  another  tumor.  Uterus  and  tumor 
movable  together,  but  not  separately  unless  tumor  is  pediculated. 

16.  Discharge  from  Uterus.  Usually  there  is  a  discharge,  due  to  com- 
plicating endometritis  (simple  or  infected). 

17.  Discoloration  of  Cervix  or  Vagina.  None,  except  what  can  be  ac- 
counted for  by  evident  pressure  on  vessels. 

18.  Relation  of  Mass  to  Tube  and  Ovary.  No  connection  with  tube  or 
ovary,  except  possibly  lying  against  them.  Tube  and  ovary  of  each  side 
may  be  felt  (if  abdominal  wall  not  too  tense),  unless  mass  is  so  large  or  so 
situated  as  to  obscure  them. 

19.  Relation  to  Pelvic  Wall.  No  connection  with  pelvic  wall,  except  when 
large  enough  to  extend  to  it  or  when  complicated  by  inflammation  or  another 
tumor. 

20.  Relation  to  Vaginal  Wall.  Depends  on  situation  of  tumor,  usually 
well  above  wall.  "When  in  cervix,  the  mass  lies  against  vaginal  wall,  just  be- 
neath examining  finger. 

21.  Bladder.  May  be  compressed  by  mass  and  distorted,  or  may  be  pulled 
up  into  abdomen  (Pig.  622). 

22.  Rectum.  May  be  pressed  upon  to  such  an  extent  as  to  cause  hemor- 
rhoids. 

23.  Mass  Elsewhere.  In  addition  to  the  main  tumor  springing  from  the 
uterus,  one  or  more  other  nodules  may  usually  be  felt  in  some  other  part  of 
the  uterus. 

24.  Colon  or  Small  Intestine  in  Front.  Not  unless  retroperitoneal  or  com- 
plicated by  adhesions. 


726  NON-MALIGNANT   TUMORS   OF   UTERUS 

25.  Outline  of  Dullness.  Dullness  over  mass  and  resonance  elsewhere,  un- 
less complicated  by  ascites. 

26.  Shifting-  Outline  of  Dullness.  No  change  in  outline  of  dullness  on 
change  of  position  of  patient,  except  when  complicated  by  ascites  or  when 
tumor  rolls  some  in  the  abdomen. 

27.  Hard  Masses  within  a  Cystic  Mass.  Nothing  like  this,  simulating  fe- 
tal parts  in  the  uterus,  except  rarely  when  complicated  by  ascites.  One  case 
is  recorded  in  which  this  condition  was  present  and  even  ballottement  could 
be  secured  (Fig.  429). 

28.  Pulsation  of  Mass.  No  pulsation  felt,  unless  tumor  lies  over  aorta. 
To  differentiate  betAveen  this  pulsation  and  that  of  aneurysm  of  aorta,  pal- 
pate well  doAvii  to  the  sides  of  the  mass  to  see  if  there  is  expanding  or  lateral 
pulsation. 

29.  Fetal  Movements.  None  felt.  In  a  large  smooth  tumor,  suspicious 
of  pregnancy  near  term,  dip  the  hands  in  cold  water  and  then  palpate  the 
abdomen,  watching  for  fetal  movements. 

30.  Vascular  Murmur.  May  or  may  not  be  murmur  in  region  of  large  ves- 
sels. 

31.  Fetal  Heart  Sounds.  None  heard.  Fetal  heart  sounds  are  often  liot 
heard  in  full  term  pregnancy,  consequently  not  much  value  attaches  to  their 
absence  in  excluding  pregnancy. 

32.  Fever.  No  fever  unless  there  are  complications  in  the  pelvis  or  else- 
where. 

33.  Emaciation  or  Fat  Deposition,  There  may  be  either  or  neither.  If 
much  hemorrhage,  usually  anemia  and  some  emaciation. 

34.  Breast  Disturbance.  None  ordinarily,  though  occasionally  there  is 
some  tenderness. 

35.  Evidence  of  Disease  Elsewhere.    None,  unless  complicated. 

The  usual  symptoms  with  the  history  and  general  course  have  already 
been  given. 

In  a  doubtful  case  it  may  be  necessary  to  run  over  the  other  points  (36  to 
63)  in  the  Diagnostic  Table  (pages  327  to  329). 

When  making  the  diagnosis  of  fibromyoma  of  the  uterus,  the  following 
conditions  and  questions  must  be  considered : 

A.  Other  diseases  presenting  a  mass  or  induration,  which  may  be  mis- 
taken for  a  fibroid.  The  more  common  of  these  diseases  are  salpingitis  with 
exudate,  pelvic  cellulitis,  hydrosalpinx,  pregnancy,  extrauterine  pregnancy, 
pelvic  tuberculosis,  ovarian  or  parovarian  tumor,  cancer  of  the  uterus. 

B.  Diseases  of  the  uterus  without  a  mass  or  induration,  which  may  be 
mistaken  for  fibroid.  For  example,  retrodisplaced  uterus  with  chronic  endo- 
metritis, chronic  endometritis  Avith  subinvolution,  carcinoma  of  corpus  uteri, 
tuberculosis  of  uterus,  prolapse  of  uterus,  inversion  of  uterus. 

C.  Fibroid  with  complications.    In  a  case  presenting  anomalous  symptoms, 


TREATMENT    OF   FIBROMYOMA  727 

the  condition  may  be  a  fibroid  complicated  Avith  pregnancy  or  extrauterine 
pregnancy  or  salpingitis  or  ovarian  tumor  or  broad  ligament  tumor  or  ma- 
lignant disease  of  the  uterus. 

D.  Additional  questions.  After  it  has  been  established  that  a  uterine  fibro- 
myoma  is  present,  the  following  points  are  to  be  considered: 

1.  Does  the  fibroid  tumor  cause  all  the  symptoms?    If  not,  what  symp- 

toms are  caused  by  it?    What  causes  the  other  symptoms'? 

2.  What  is  the  relation  of  the  tumor  or  tumors  to  the  uterine  wall  and 

cavity? 

3.  What  is  the  relation  of  the  tumor  or  tumors  to  the  other  pelvic  or- 

gans and  to  the  pelvic  wall  and  to  the  peritoneum? 

4.  What  complications  are  present — particularly  pregnancy,  malignant 

disease,  pelvic  inflammation,  heart  disease,  kidney  disease? 

5.  What  has  been  the  progress  of  the  disease  in  this  case,  and  what  will 

probably  be  the  further  progress? 

TREATMENT 

In  regard  to  treatment  there  are  three  propositions  to  be  considered :  (A) 
no  treatment,   (B)  palliative  treatment  and  (C)   curative  treatment. 

A.  NO  TREATMENT 

A  certain  small  percentage  of  fibromyomata  are  discovered  by  accident, 
i.  e.,  during  a  pelvic  examination  for  symptoms  not  due  to  the  fibroid.  The 
fibroid  is  small,  has  caused  no  symptoms,  is  not  likely  to  cause  symptoms 
soon,  and  is  not  likely  to  aggravate  the  symptoms  due  to  the  other  trouble. 

Such  a  tumor  requires  no  treatment,  and  it  is  just  as  well,  as  a  rule,  that 
the  patient  be  not  informed  of  its  presence.  She  should,  however,  be  kept 
under  observation,  to  see  if  there  is  any  increase  in  the  growth.  Explain  the 
condition  to  the  husband  or  other  responsible  relative,  that  your  skill  be  not 
called  in  question  should  the  patient  be  examined  by  some  other  physician 
and  the  presence  of  a  tumor  announced. 

There  is  one  class  of  small  fibroids,  that  the  author  constitutes  an 
exception  to  this  rule  of  "no  symptoms,  no  treatment,"  namely,  cervix  fi- 
broids. When  situated  in  the  lower  part  of  the  uterus,  a  fibroid  of  any  con- 
siderable size  is  a  dangerous  matter  in  the  child-bearing  period.  If  pregnancy 
should  take  place,  the  tumor  will  probably  increase  in  size  and  may  become 
a  serious  menace  to  labor  at  term.  Again,  a  cervix  fibroid  is  likely  to  cause 
symptoms  (bladder,  rectal  or  menstrual)  at  any  time,  even  though  small. 
Such  a  tumor  in  a  married  woman  should  be  removed.  If  not  complicated  by 
tumors  elsewhere  in  the  uterus,  it  may  be  approached  from  the  vagina  and 
removed  by  a  comparatively  simple  operation. 


728  NON-MALIGNANT    TUMORS   OF    UTERUS 

B.  PALLIATIVE  TREATMENT 

Palliative  treatment  is  symptomatic.  It  is  directed  towards  relieving  the 
disturbances  occasioned  by  the  fibroid  and  making  the  patient  more  comfort- 
able. The  principal  disturbances  requiring  the  palliative  treatment  are  the 
bleeding  and  the  pressure  symptoms. 

Measures  for  Palliative  Treatment 

The  palliative  measures  are  (1)  tonic  measures,  (2)  uterine  astringents, 
(3)  vaginal  packings,  (4)  intrauterine  treatment,  (5)  ligation  of  uterine  ar- 
teries, and  (6)  removal  of  ovaries  with  ligation  of  ovarian  arteries,  (7)  treat- 
ment with  X-rays  and  radium,  Mdiich  in  a  considerable  percentage  of  the 
cases  yields,  not  only  a  palliative,  but  a  permanently  curative,  effect. 

1.  General  Tonic  and  Hyg-ienic  Measures.  The  better  the  patient's  gen- 
eral health,  the  less  the  annoyance  from  the  fibromyoma.  Consequently  there 
should  be  employed  laxatives  (as  in  pelvic  inflammation),  tonic  medicines, 
avoidance  of  long  walks,  rest  at  the  menstrual  periods,  douches  as  indicated 
by  discharge,  and  a  general  regime  to  improve  the  general  health  and  dimin- 
ish pelvic  congestion. 

2.  Uterine  Astringents.  These  are  hemostatic  remedies,  administered  for 
the  purpose  of  diminishing  the  bleeding  (menorrhagia  and  metrorrhagia). 
The  hemostatic  remedies  thus  used  are  ergotin,  stypticin,  hydrastinin,  adre- 
nalin (preferable  to  thyroid  extract  or  mammary  extract)  and  calcium- 
chloride. 

Ergotin  is  the  one  that  has  been  most  extensively  used.  It  is  an  exceed- 
ingly useful  remedy  for  temporarily  lessening  the  menorrhagia.  Continued 
for  several  months  in  one  grain  to  two  grain  doses  it  produces  marked  im- 
provement in  certain  cases.  Other  tonics  may  be  combined  with  the  ergotin 
and  if  there  is  much  pain  it  is  well  to  combine  also  a  sedative  such  as  can- 
nabis indiea. 

Byford  cites  a  series  of  101  fibroid  cases  treated  by  ergot.  Twenty  were 
reported  cured.  In  39  others  the  tumor  was  reduced  in  size  and  the  symptoms 
relieved.  In  19  others  the  hemorrhage  diminished  but  the  tumor  remained 
the  same  size.  In  21  there  was  no  effect.  Nelson  collected  153  cases  treated 
by  ergot,  of  which  11  died.  Even  in  cases  where  operation  is  necessary,  er- 
got (preferably  in  the  form  of  ergotin)  is  a  useful  palliative  measure  while 
the  patient  is  waiting. 

3.  Vaginal  Treatment.  Antiseptic  vaginal  douches  are  required  in  cases 
presenting  leueorrhea  or  bloody  discharge.  Vaginal  packing  may  be  needed  to 
check  bleeding  temporarily  or  to  raise  an  impacted  tumor  out  of  the  pelvis. 
A  firm  vaginal  packing  of  antiseptic  gauze,  or  of  cotton  (made  antiseptic  by 
iodoform  and  tannic  acid  equal  parts,  dusted  in  freely)  is  an  excellent  meas- 
ure for  temporary  control  of  bleeding  from  within  the  uterus.    The  patient  is 


TREATMENT   OF   FIBROMYOMA  729 

kept  quiet  in  bed  and  the  packing  changed  every  two  or  three  days  as  nec- 
essary to  prevent  decomposition.  This  may  be  used  in  conjunction  with  uter- 
ine astringents,  to  control  bleeding  temporarily,  while  the  patient  is  being  built 
up  for  operation  or  is  being  taken  to  a  place  for  operation.  When  the  bleed- 
ing can  be  thus  controlled,  the  dangers  of  intrauterine  disturbance  (packing, 
instrumentation)  are  thus  avoided. 

4.  Intrauterine  Measures.  The  intrauterine  measures  for  the  control  of 
the  hemorrhage  are  (a"^  electricity,  (b)  curetment  and  (c)  applications  and 
packing. 

a.  Electricity,  In  certain  cases  of  small  interstitial  or  submucous  growths, 
this  is  a  useful  palliative  measure.  The  details  of  the  application  of  electricity 
for  uterine  bleeding  are  given  in  Chapter  in  (page  399). 

The  use  of  heavy  currents,  running  up  to  200  and  250  ma.  (Apostolic 
method),  w^ith  or  without  puncture,  is  not  advisable.  It  is  too  hazardous  for 
the  uncertainty  of  result.  It  may  cause  serious  necrobiotic  or  infiammatorj'- 
changes,  which  add  very  much  to  the  danger  of  the  subsequent  operation, 
and  it  has  even  caused  death.  It  is  not  to  be  recommended  except  in  urgent 
conditions  where  the  patient  can  not  undergo  operation  for  the  removal  of  the 
gro\vth.  Some  still  cling  to  it  as  a  curative  measure.  Massey,  of  Phila- 
delphia, in  reporting  86  eases  subjected  to  this  treatment,  stated  that  64 
resulted  in  "practical  success"  (symptomatic  cure)  and  of  these  the  tumor 
was  ''extruded  through  the  cervix  in  whole  or  in  part  or  in  4  per  cent,  disap- 
peared by  absorption  in  12  per  cent,  and  was  reduced  in  size  in  3  per  cent." 
Hirst,  of  Philadelphia,  Avho  was  one  of  a  committee  of  three  appointed  by  the 
Philadelphia  County  Medical  Society  to  investigate  this  treatment,  states  that 
"in  three  years'  time  not  a  single  case  was  presented  to  us  of  a  tumor  re- 
duced in  size  by  electrical  treatment." 

4  Even  the  use  of  the  milder  currents,  as  first  mentioned  above,  presents 
the  usual  dangers  of  intrauterine  instrumentation  and  is,  as  a  rule,  advisable 
only  in  non-operable  cases,  or  in  operable  cases  only  to  control  otherwise  un- 
controllable bleeding  until  the  patient  can  be  got  in  condition  for  oper- 
ation, 

b.  Curetment.  This  may  control  bleeding  temporarily  in  those  cases  in 
which  the,  bleeding  is  due  to  hyperplasia  of  the  endometrium.  In  many  cases, 
however,  the  cavity  is  so  distorted  that  the  curet  can  only  wound  parts  of  the 
wall  here  and  there  without  removing  the  entire  endometrium.  In  addition 
to  this  uncertainty  of  controlling  the  hemorrhage,  there  is  danger  of  infec- 
tion of  the  uterine  wall  or  infection  and  necrosis  of  the  growth,  leading  to 
an  exceedingly  dangerous  condition.  Schroeder  reports  a  case  of  necrosis 
of  a  submucous  tumor,  the  capsule  of  which  had  been  torn  by  the  curet. 

In  carefully  selected  cases,  curetment  may  be  advisable,  partially  as  a 
diagnostic  measure,  but  there  must  be  a  clear  understanding  of  the  dangers 
incident  to  it  and  good  reason  for  taking  the  risk.     In  the  hands  of  those 


730  NON-MALIGNANT    TUMORS    OF    UTERUS 

experienced  in  the  selection  of  cases  and  in  the  use  of  the  curet,  the  prob- 
ability of  any  serions  complication  from  a  clean  curetment  is  not  great.  But 
there  is  great  risk  in  careless  intrauterine  instrumentation  in  these  eases, 
even  the  simple  introduction  of  the  uterine  sound   (see  Figs.  610,  611). 

c.  Intrauterine  applications.  These  are  dangerous  and  inefficient.  In 
inoperable  cases  the  judicious  use  of  the  curet  or  of  electricity  is  preferable. 
Occasionally,  as  an  emergency  measure  for  the  immediate  control  of  alarm- 
ing hemorrhage,  intrauterine  packing  may  be  used.  But  usually  a  firm  vag- 
inal packing  will  secure  the  same  results  without  the  dangers  incident  to 
intrauterine   instrumentation. 

5.  Ligation  of  the  Uterine  Arteries  to  diminish  the  blood  supply  to  the 
growth  and  check  the  bleeding.  There  has  been  considerable  dispute  as  to 
who  is  entitled  to  the  claim  of  priority  in  originating  vaginal  ligation  of  the 
uterine  arteries  for  this  disease.  W.  B.  Dorsett  suggested  it  in  1890  in  an 
article  entitled  ''A  Case  of  Atrophy  of  the  Female  Genitalia  Following  Preg- 
nancy, and  Eemarks."  Gottschalk,  in  an  article  published  in  1892  remarked 
that  ligation  of  the  uterine  arteries  might  be  a  useful  measure  and  stated 
that  he  had  performed  the  operation  in  two  cases.  Franklin  H.  Martin  sug- 
gested vaginal  ligation  of  the  base  of  the  broad  ligaments  in  1893,  and  in 
1894  reported  six  cases  treated  by  this  method.  Several  series  of  cases  have 
since  been  reported.  The  operation  proves  disappointing  in  a  large  propor- 
tion of  the  cases. 

Since  the  perfection  of  myomectomy  and  hysterectomy,  this  uncertain 
method  is  applicable  only  in  exceptional  cases.  It  is  useful  in  certain  pa- 
tients who  are  in  too  bad  a  condition  for  operation  for  removal  of  the  tu- 
mor. Also,  it  may  be  tried  in  patients  who  refuse  radical  methods  and  prefer 
to  submit  to  the  smaller  and  less  serious  operation.  Only  interstitial  growths 
are  suitable  for  it,  and  the  operation  should  be  conducted  so  as  to  ligate 
practically  all  the  main  vessels  supplying  the  region  of  the  growth.  In  cases 
where  the  vessels  in  the  upper  part  of  the  broad  ligaments  can  be  reached 
from  below,  they  also  should  be  ligated. 

6.  Remova-l  of  the  Ovaries,  with  ligation  of  the  ovarian  arteries.  This 
operation  cuts  off  the  blood  supply  through  the  upper  part  of  each  broad 
ligament  and  also  stops  the  recurring  menstrual  congestion.  There  is  fre- 
quently considerable  difficulty  in  reaching  the  adnexa  and  vessels,  because  the 
tumor-mass  is  in  the  way  or  because  of  complicating  adhesions  from  tubal 
inflammation,  so  there  is  more  danger  attached  to  it  than  one  might  at  first 
thought  suppose.  In  a  reported  series  of  29  cases  there  were  3  deaths. 
In  another  reported  series  of  262  cases  the  mortality  was  1.5  per  cent. 

As  an  operation  of  choice,  it  is  not  to  be  compared  to  removal  of  the 
growth,  but  as  an  operation  of  necessity,  it  may  do  much  good.  For  ex- 
ample, when  the  abdomen  has  been  opened  and  the  tumor  found  of  such 
character  or  with  such  complications  that  its  removal  it  not  advisable,  or 
when  the  patient  suddenly  passes  into  such  serious  condition  during  oper- 


TREATMENT   OF   PIBROMYOMA  731 

atioii  that  the  contemplated  radical  operation  can  not  be  proceeded  with, 
then  the  ovarian  vessels  and  other  vessels  within  easy  reach  may  be  quickly 
ligated  and  the  ovaries  removed  and  the  abdomen  closed. 

Of  course,  every  particle  of  ovarian  tissue  must  be  removed  if  the  ces- 
sation of  menstruation  is  to  be  secured,  though  the  simple  ligation  of  the 
principal  vessels  supplying  the  tnmor  may  make  some  improvement.  The  en- 
largement of  the  blood  vessels  in  the  vicinity  of  the  tumor,  adds  materially 
to  the  danger  of  the  operation.  Fatal  hemorrhage  has  occurred  from  the 
puncture  of  a  dilated  vessel  by  the  pedicle  needle. 

In  the  light  of  modern  knowledge  the  beneficial  effect  of  a  bilateral  ovari- 
otomy (castration)  on  a  uterine  fibromyoma  is  due  to  the  elimination  of  all 
ovarian  internal  secretion  which  periodically,  under  normal  conditions,  and  ir- 
regularly, in  case  of  hyp  erf  unction,  leads  to  congestion  of  the  endometrium, 
i.  e.,  to  uterine  hemorrhage. 

7.  Treatment  with  X-rays  and  Radium  more  readily  achieves  the  identical 
result.  Only  a  few  applications  of  penetrating  rays  in  fairly  large  doses 
quickly  cause  a  complete  destruction  of  the  follicle  apparatus  in  the  ovary. 
The  immediate  result  is  sterility  and  amenorrhea,  a  point  worthy  of  careful 
consideration  when  this  treatment  is  contemplated  in  a  young  woman  of 
child-bearing  age,  possibly  desirous  of  offspring. 

The  effect  upon  the  fibromatous  growth  is  chiefly  indirect.  Exactly  as 
cessation  of  ovarian  funtion  leads  to  an  atrophy  of  the  uterus  in  the  form  of 
involution,  it  effects  in  an  identical  manner  a  gradual  reduction  in  size,  and 
may  finally  result  in  complete  disappearance  of  a  fibromyoma.  To  a  certain 
extent,  however.  X-rays,  and  particularly  radium  rays,  affect  directly  the 
fibromatous  tissue  itself.  Not  every  fibromyoma  of  the  uterus  is  suitable 
for  this  treatment.     As  distinct  contraindications  should  be  regarded: 

1.  Any  suspicion  of  malignancy.  In  most  instances  it  will  be  advisable 
to  exclude  malignancy  by  means  of  a  careful  diagnostic  curettage  with  micro- 
scopic study  of  the  scrapings. 

2.  Degenerative  changes  in  the  growth.  Cystic  degeneration  often  is 
suggested  by  the  softness  of  the  tumor  or  actual  fluctuation,  necrotic  and 
suppurative  changes  by  elevation  of  temperature,  pain  and  tenderness  to 
pressure,  and  calcareous  degeneration  by  the  consistency  of  the  mass. 

3.  Symptoms  due  to  pressure  against  bladder,  ureter,  rectum,  nerve 
trunks,  etc. 

4.  Profusely  bleeding  submucous   myomata. 

5.  The  complication  with  acute  inflammatory  process  in  tubes  or  ovaries. 

6.  All  urgent  symptoms,  local  or  general,  which  require  quick  action 
(pedicle  twist,  septic  symptoms,  etc.). 

As  special  indications  in  favor  of  the  radiologic  treatment  must  be  con- 
sidered all  conditions  which  render  the  patient  a  poor  surgical  risk,  such  as 
extreme  thickness  of  abdominal  walls,  advanced  age,  complicating  heart  or 
kidney  diseases,  etc. 


732  NON-MALIGNANT    TUMORS   OF    UTERUS 

With  a  proper  selection  of  eases  the  results  are  extremely  satisfactory. 
Various  reports,  covering  large  numbers  of  eases,  claim  permanent  cures  in 
approximately  75  per  cent  of  the  cases.  Kroenig  and  Gauss  of  the  Freiburg 
Clinic,  who  deserve  credit  for  having  successfully  elaborated  and  enthusi- 
astically advocated  the  X-ray  treatment  of  uterine  fibromyomata,  state  posi- 
tively that  the  cures  in  their  own  experience  reach  the  figure  of  100  per  cent. 

The  objection  raised  occasionally  that  X-ray  treatment  is  actually  re- 
sponsible for  the  development  of  carcinoma  and  sarcoma  in  the  roentgenized 
growth  seems  successfully  repudiated  by  those  who  claim  that  in  these  in- 
stances an  already  existing  malignant  condition  simply  had  been  overlooked, 
often  as  the  result  of  avoidable  carelessness. 

X-ray  treatment  applied  by  an  expert  with  proper  equipment  has  not 
superseded  the  operative  treatment  of  uterine  fibroids,  but  has  undeniably 
greatly  reduced  the  percentage  of  those  cases  in  which  operation  should  be 
performed. 

The  best  summary  of  the  status  of  radium  treatment  will  be  found  in  a 
recent  paper  of  Burnam  (Bull,  of  Johns  Hopkins  Hospital,  1915),  based  on 
personal  experience  with  almost  1300  cases.  Radium  applied  locally  to  the 
endometrium  in  this  respect  has  a  great  advantage  over  the  X-rays  and, 
therefore,  is  most  successfully  used  in  the  cases  of  severe  hemorrhage.  The 
results  are  prompt  and  complete. 

In  95  per  cent  of  uterine  fibromyomata  Burnam  (and  Kelly)  obtained 
permanent  cures  by  means  of  local  applications  of  radium  tubes,  and  only  in 
5  per  cent  the  growth  seemed  to  remain  uninfluenced. 

Indications  for  Palliative  Treatment 

Palliative  treatment  is  required  in  the  following  classes  of  cases: 

1.  When  the  symptoms  are  slight  and  transitory.  In  some  of  these  cases 
the  judicious  employment  of  palliative  measures  No.  1  and  No.  2,  will  relieve 
the  pelvic  disturbance  so  much  that  the  patient  is  symptomatically  a  well 
woman. 

2.  When  the  patient  is  not  in  condition  for  operation,  because  of  some 
temporary  trouble.  In  some  cases  the  patient  is  so  anemic  that  to  subject 
her  to  a  major  operation  would  be  a  most  serious  menace,  hence  the  necessity 
of  preparatory  treatment.  It  may  be  necessary  to  employ  palliative  measures 
for  several  weeks  before  the  operation.  The  percentage  of  hemoglobin  should 
be  brought  up  to  at  least  50  per  cent  if  possible,  and  the  red  blood  corpuscles 
to  3,000,000. 

3.  When  the  patient  is  debarred  from  operation  by  some  permanent  trou- 
ble.    In  these  cases,  the  palliative  measures  must  be  employed  indefinitely. 

4.  When  the  patient  refuses  operation.  Some  patients  prefer  to  get  along 
as  best  they  can,  rather  than  undergo  a  serious  operation.     In  all  of  these 


TREATMENT    OF   FIBROMYOMA  733 

cases,  much  relief  can  be  given  by  palliative  measures  judiciously  employed, 
and  some  may  be  kept  in  comparative  comfort  indefinitely. 

C.  CURATIVE  TREATMENT 

Having  given  above  the  facts  concerning  treatment  with  X-rays  and  ra- 
dium, we  may  still  claim  that  the  only  reliable  curative  treatment  for  uterine 
fibromyomata  is  removal  by  operation. 

Operative  Measures 

The  various  operative  measures  looking  to  the  removal  of  the  growth  are 
as  follows : 

Myomectomy — Removal  of  the  tumor  or  tumors  and  preservation  of  the 
uterus.  ,    '1    M''    I  ■' 

Abdominal  Myomectomy — Enucleation  from  the  outer  surface  of  the  uterus. 

Vaginal  Myomectomy — Enucleation  from  the  outer  surface  of  the  uterus 
(cervix)  or  from  the  inner  surface  (by  splitting  the  uterus) . 

Supravaginal  Hysterectomy.  Removal  of  the  tumor  and  of  the  body  of 
the  uterus,  leaving  the  cervix.  This  is,  of  course,  carried  out  through  the 
abdomen  and  is  the  form  of  operation  usually  referred  to  as  "  abdominal  hys- 
terectomy for  fibroid"  and  ''abdominal  hystero-myomectomy. " 

Total  Hysterectomy.  Removal  of  the  tumor  and  of  the  entire  uterus,  in- 
cluding the  cervix.  This  is  carried  out  through  the  abdomen  or  through  the 
vagina,  as  thought  best  in  the  particular  case.  In  certain  exceptional  cases 
it  is  preferable  to  carry  out  the  operation  as  a  combined  vaginal  and  abdomi- 
nal hysterectomy. 

Each  of  the  operative  measures  given  above  has  its  advantages  and  dis- 
advantages in  various  classes  of  cases.  While  there  is  not  space  here  for  a 
general  discussion  of  this  subject  it  may  be  advisable  to  call  attention  to  cer- 
tain precautions  that  should  be  taken  in  order  to  avoid  cancer  of  the  cervical 
stump  after  supravaginal  hysterectomy.    . 

The  physiologic  and  technical  advantages  of  leaving  the  cervix  are  be- 
yond question.  The  stubborn  fact,  that  will  not  down  and  that  stands  as  a 
specter  imperatively  demanding  a  close  study  of  the  question  is  this:  that  in 
a  number  of  cases  treated  by  supravaginal  hysterectomy,  the  patient  has  later 
died  of  malignant  disease  of  the  cervix.  It  is  easy  to  say  "for  that  reason 
we  should  remove  the  cervix  in  all  cases."  That  would  be  an  easy  solution  of 
the  problem  so  far  as  the  operator  is  concerned,  but  it  would  not  be  the  best 
from  the  standpoint  of  results  to  the  patient.  The  mortality  would  be  higher 
and  the  morbidity  would  be  higher — all  for  the  purpose  of  attaining  a  se- 
curity which  the  author  is  satisfied  can  be  obtained  in  a  way  that  is  decidedly 
safer,  though  somewhat  more  troublesome. 


734  N-ON-MALIGXAXT    TUISIORS    OF    UTERUS 

This  seciu'ity  is  obtained  by  observing  the  following  precautions  before  and 
during  and  after  operation: 

Before  Operation". 

1.  Examine  carefully  to  exclude  malignant  disease  of  the  cervix  or  cor- 
pus uteri,  in  suspicious  cases  making  a  microscopic  examination  of  clippings. 
If  malignant  disease  is  found,  of  course,  total  hysterectomy  with  wide  removal 

of  the  parametrium  is  indicated. 

2.  Ascertain  if  the  cervix  is  severely  lacerated  or  the  seat  of  chronic 
irritation  from  any  cause.     If  so.  employ  total  hysterectomy. 

3.  If  there  has  been  recent  infection  in  the  uterine  cavity  or  adjacent 
tissues,  with  the  development  of  a  condition  making  immediate  operation  nec- 
essary, employ  total  hysterectomy. 

4.  In  some  cases  total  hysterectomy  is  required  because  of  the  situation 
of  the  tumor. 

In  all  other  cases  requiring  removal  of  the  uterus,  supravaginal  hysterec- 
tomy is  the  preferable  operation. 

DuRixG  Operatiox 

5.  As  soon  as  the  tumor  is  removed,  have  a  responsible  assistant  open  it 
and  make  a  rapid  and  critical  examination  of  the  tumor  and  uterus.  If  ami;hing 
suggesting  malignant  change  is  found,  remove  the  cervix. 

After  Operation 

6.  After  operation  submit  all  specimens  to  a  microscopic  examination, 
of  sufficient  thoroughness  to  determine  the  presence  or  absence  of  malig- 
nant intiltration.  If  malignant  change  is  found,  promptly  remove  the  cer- 
vical stump.    This  can  be  readily  done  per  vaginam. 

By  these  measures,  supravaginal  hysterectomy  is  limited  to  cases  in  which 
the  cervix  is  practically  normal  and  in  which  the  chance  of  development  of 
malignant  disease  is  so  slight  as  not  to  constitute  a  practical  contraindication 
to  preservation  of  the  cervix. 

Indications  for  Operation 

In  what  cases  is  removal  of  the  groAvtli  advisable?  As  a  general  proposi- 
tion it  may  be  stated  that  the  growth  should  be  removed  when  there  are 
troublesome  symptoms  which  persist  after  the  employment  of  palliative  meas- 
ures Xo.  1  and  Xo.  2,  or  in  winch  the  conditions  are  such  that  those  meas- 
ures are  not  likely  to  give  relief.     In  a  considerable  proportion  of  the  cases 


TREATMENT   OP    FIBROMYOMA  735 

the  symptoms  are  so  severe  and  threatening  that  there  is  no  question  as  to 
the  advisability  and  urgency  of  operation  for  removal. 

In  the  majority  of  cases,  however,  the  symptoms  are  not  so  severe  nor 
threatening,  and  by  palliative  measures  the  patient  may  be  made  fairly  com- 
fortable for  a  time.  In  such  cases  should  the  tumor  be  removed  or  should  it 
be  left  alone  until  serious  symptoms  develop?  This  is  one  of  the  most  im- 
portant problems  iww  before  gynecologists  for  solution.  The  facts  so  far 
available  indicate  that  in  those  cases  with  persistent  symptoms,  the  inter- 
ests of  the  patient  are  best  conserved  by  the  removal  of  the  growth  while  the 
patient  is  still  in  good  condition  and  the  risk  accordingly  small.  If  further 
experience  confirms  this,  it  Avill  mark  one  of  the  most  important  advances 
in  surgery — ranking  with  the  establishment  of  the  interval-operation  in  ap- 
pendicitis. 

To  present  this  important  subject  clearly,  the  author  gives  the  foUoAving 
quotation  from  a  paper  read  before  the  Missouri  State  Medical  Association 
in  May,  1906.*^ 

''In  order  to  come  quickly  to  the  point  I  will  eliminate  at  once  those 
classes  of  cases  about  which  there  is  practically  no  question. 

"1.  Cases  in  which  the  tumor  causes  no  symptoms.  These  are  seen  by 
the  physician  only  rarely  and  then  usually  by  accident. 

"2.  Cases  in  which  the  tumor  is  small  and  is  causing  only  slight  symp- 
toms (moderate  menorrhagia  or  dysmenorrhea  which  are  relieved  by  general 
tonic  treatment  with  the  addition  of  uterine  astringents — ergotin,  stypticin, 
hydrastis),  and  the  symptoms  do  not  return  soon  after  the  treatment  has 
been  discontinued. 

"3.  Cases  in  which  the  patient  is  past  45  years  of  age  and  the  tumor  is 
stationary  in  size,  not  large  enough  to  cause  disturbing  pressure  symptoms, 
accompanied  by  only  moderate  menorrhagia  and  without  troublesome  inter- 
menstrual symptoms. 

"It  will  hardly  be  questioned  that  for  these  three  classes  the  expectant 
plan  is  the  preferable  treatment. 

"4c.  Cases  presenting  conditions  that  threaten  life  or  cause  persistent  se- 
vere suffering.  The  necessity  of  operation  in  this  class  has  long  been  gener- 
ally recognized. 

"It  is  the  cases  which  lie  betvv'een  these  two  extremes  to  which  I  wish  to 
direct  your  attention.  What  is  the  best  treatment  for  the  patients  who  have 
no  threatening  symptoms?  They  come  for  advice  and  treatment  and  the  ques- 
tion is:  What  is  best  to  do  for  them? 


*Some  Questions  Concerning  the  Treatment  of  Uterine  Fibromyomata,  H.  S.  Crossen,  M.D.,  Journal 
of  Missouri  State  Medical  Association,  Vol.   Ill,  No.   3,   1906. 

This  paper  written  eleven  years  ago  obviously  does  not  reflect  the  radical  changes  brought  about 
by  the  present  successful   radiologic  treatment   of  uterine   fibromyomata. 

Its  complete  elimination  from  this  new  edition  would  deprive  the  readers  of  much  valuable  informa- 
tion. On  the  other  hand  it  seemed  both  impossible  and  undesirable  to  make  the  necessary  changes  without 
consultation  with  its  author,  Dr.  Crossen,  at  present  on  war  duty  in  France.  Enough  information  has 
been  offered  in  the  preceding  pages  concerning  the  present  status  of  the  X-ray  and  radium  treatment  of 
uterine  fibroids  to  permit  the  discriminating  reader  to  peruse  these  quotations  without  becoming  confused. — 
Hugo   Ehrenfest. 


736  NON-MALIGNANT    TUMORS    OF    UTERUS 

''The  tumor  is  of  moderate  size,  perhaps  as  large  as  the  fist  or  two  or 
three  times  as  large.  The  patient  is  fairly  well  nourished,  probably  some- 
what anemic,  but  not  seriously  so.  The  menstrual  flow  is  excessive  but  by 
the  continuous  administration  of  ergotin  or  stypticin  it  can  be  held  down  to 
very  moderate  menorrhagia.  The  backache  and  pelvic  pressure  are  very 
troublesome  at  the  menstrual  periods  but  between  periods  the  patient  feels 
fairly  well  and  is  able  to  do  her  work  and  attend  to  her  social  duties.  She 
feels  dragged  out  a  good  part  of  the  time  and  has  backache  and  pelvic  dis- 
comfort after  extra  exertion.  The  patient  is  a  semi-invalid — not  sick  enough 
to  be  called  sick  and  not  well  enough  to  be  called  well. 

"She  is  between  30  and  40  years  of  age  and  has  been  under  treatment, 
including  a  general  tonic  regime  with  the  addition  of  uterine  astringents, 
long  enough  to  make  it  plain  that  the  condition  described  is  the  best  that 
can  be  obtained  short  of  operation. 

"What  advice  shall  we  give  such  a  patient?  Should  the  tumor  be  let 
alone  or  should  it  be  removed? 

"It  is  easy  to  say  to  the  patient:  'Wait.  There  is  no  special  indication 
for  operation  just  now,  there  may  be  no  serious  increase  in  the  symptoms  at 
any  time,  and  it  is  possible  that  after  the  menopause  the  troublesome  symp- 
toms will  largely  disappear.' 

"The  points  made  in  that  advice  are  all  literally  true  and  the  advice 
itself  seems  plausible.  But  when  some  complication  that  would  have  been 
prevented  by  early  removal  of  the  tumor,  rapidly  causes  the  death  of  our 
patient  or  forces  her  to  operation  with  quadrupled  risk,  we  begin  to  doubt 
the  wisdom  of  the  waiting  advice.  This  is  not  a  picture  of  fancy.  Nearly 
all  the  fibromyoma  cases  that  Avere  operated  on,  the  world  over  previous  to 
the  last  two  or  three  years,  and  the  larger  part  of  those,  that  are  operated  on 
today,  have  passed  through  the  process  just  mentioned. 

' '  The  patient  went  to  a  physician  who  treated  her  expectantly,  according 
to  the  established  usage,  and  congratulated  himself  that  she  was  getting 
along  pretty  well.  And  she  was  'getting  along  pretty  well' — 'pretty  well' 
toward  a  condition  that  greatly  increased  the  risk  of  the  operation  which 
was  finally  necessary. 

"I  may  speak  plainly  for  I  speak  from  experience.  The  cap  fits  and  I 
put  it  on — I  trust  others  will  do  the  same. 

"In  many  cases  the  physician  who  long  treated  the  patient  loses  the 
lesson  of  the  case  through  no  fault  of  his  own.  Some  of  these  patients  pass 
through  many  hands  in  the  various  stages  of  the  tumor's  growth,  for  it  ex- 
tends through  many  years.  Perhaps  half  a  dozen  physicians  have,  from  the 
same  case,  been  established  in  their  conclusion  that  fibroid  patients  get  along 
very  well  and  rarely  need  operation,  while  only  the  last  physician  whom  the 
patient  consults  has  the  true  lesson  of  the  case  forced  upon  him  in  a  way  that 
can  not  be  misunderstood.     In  some  cases  the  serious  condition  advances  so 


TREATMENT    OF   FIBROMYOMA  737 

rapidly  or  so  insidiously  that  the  patient  dies  without  the  consideration  of 
operative  measures,  or  is  found  in  such  condition  that  operation  is  no  longer 
possible. 

''Some  physicians  find  it  hard  to  believe  that  uterine  fibroids  really 
cause  death  except  so  rarely  that  the  cases  may  be  classed  as  curiosities.  A 
practical  experience  with  even  a  moderate  number  of  advanced  cases  will 
quickly  dispel  this  illusion,  provided  the  physican  watches  the  cases  to  their 
temninations.     Bishop  reports  27  deaths  due  to  fibroids  without  operation. 

''On  the  other  hand,  in  deciding  what  to  do  for  these  patients,  it  is 
easy  to  take  the  other  short-cut  and  advise  all  patients  with  palpable  fibroids 
to  be  operated  on — that  is,  it  is  easy  for  the  physician.  But  before  advising 
operation  in  any  case  we  must  assure  ourselves  that  the  chance  of  death  as- 
sumed is  fully  justified  by  the  danger  of  delay  in  that  particular  case.  Then, 
if  death  comes  in  spite  of  every  precaution,  we  know  at  least  that  it  was  not 
an  unwarranted  sacrifice.  It  is  easy  enough  to  advise  operation,  but  it  is  not 
easy  to  restore  life  to  the  deceased — who,  but  for  the  operation,  might  have 
lived  in  comparative  comfort  to  old  age. 

"But  what  advice  shall  we  give  our  patient?  The  symptoms  at  present 
are  not  such,  in  themselves,  as  to  necessitate  operation.  They  are  not  threat- 
ening speedy  death,  neither  are  they  causing  great  disability.  If  they  con- 
tinue as  they  are,  the  patient,  by  continuing  under  treatment,  by  lying  down 
most  of  the  menstrual  days  and  by  being  careful  at  other  times  as  to  extra 
work  and  walking,  may  live  a  fairly  comfortable  life. 

"]Many  women,  probably  most  Avomen  in  ordinary  circumstances,  would 
prefer  this  state  rather  than  seek  complete  health  through  a  dangerous  oper- 
ation, even  though  the  operative  mortality  is  small.  And  I  am  not  going  to 
condemn  such  a  choice — in  fact,  granted  the  stationary  character  of  the  trou- 
ble, I  would  strongly  advise  such  a  course. 

"But  have  we  any  well-grounded  assurance  that  the  trouble  Avill  remain 
stationary?     There  lies  the  gist  of  the  matter. 

' '  The  patient  comes  to  the  physician  to  learn,  not  what  she  already  knows, 
viz.,  that  with  the  present  symptoms  she  can  get  along  in  comparative  com- 
fort, but  she  comes  to  learn  whether  or  not  it  is  safe  for  her  to  go  along  in 
that  way.  She  v^ants  to  know  whether  she  had  better  have  the  tumor  re- 
moved now,  while  she  is  in  good  condition  and  the  risk  accordingly  small,  or 
whether  she  had  better  wait  and  see  whether  or  not  severe  symptoms'  develop. 

"This  brings  us  up  squarely  to  the  question  of  prognosis  in  this  class  of 
myoma  cases. 

"It  is  interesting,  and  pertinent  to  the  subject,  to  notice  for  a  moment 
the  method  of  development  of  surgical  treatment  in  general  and  of  abdomino- 
pelvic  surgery  in  particular. 

"At  first  major  surgery  was  invoked  in  only  the  most  desperate  cases, 
those  that  were  passing  to  certain  and  speedy  death.    This  was  proper  for,  in 


738  is^ON-MALIGNANT    TUMORS   OF   UTERUS 

the  state  of  experience  at  that  time,  the  operation  itself  meant  death  in  many 
cases.  It  was  a  desperate  remedy  for  a  desperate  condition,  and  occasionally 
attained  success.  As  the  technic  was  perfected,  more  of  the  desperate  cases 
were  rescued  from  death.  As  these  fatal  conditions  for  which  operation  was 
carried  out,  were  studied  in  conjunction  with  the  experience  gained  in  the 
operative  work,  physicians  began  to  anticipate  the  desperate  and  terminal 
conditions,  and  to  operate,  when  the  patient  was  in  a  somewhat  better  condi- 
tion— and  with  much  better  success. 

''Then  they  began  to  look  still  further  ahead  and  consider  the  possibil- 
lities  of  surgery  in  conditions  that  became  inoperable  many  months  before 
death.  Thus  was  gradually  worked  out  the  prognosis  and  required  treatment  for 
ovarian  tumors,  for  uterine  cancer  and  for  otlier  pelvic  and  abdominal  dis- 
eases that  were  found  to  prove  invariably  fatal  within  a  few  years.  The  nec- 
essity of  early  operation  in  these  conditions  that  proved  fatal  in  a  compara- 
tively short  time,  was  soon  established,  and  gained  general  acceptance  long 
ago.  The  course  of  such  diseases  was  quickly  run.  Within  the  short  period 
of  a  few  years,  the  physician  saw  the  patient  a  well  woman,  then  the  disease 
beginning,  then  its  full  development  and  then  the  invariable  death,  this  series 
of  events  taking  place  so  quickly  that  it  was  all  under  the  one  physician  and 
within  his  recent  recollection.     The  lesson  was  obvious — delay  meant  death. 

"That  field  conquered,  surgical  attention  was  directed  to  the  question 
of  early  operation  in  those  diseases  which,  though  not  invariably  causing 
death,  nevertheless  frequently  caused  death  and  in  another  large  propor- 
tion of  the  cases  caused  persistent  suffering  and  invalidism.  Then  was 
worked  out  the  advisability  of  operation  in  the  quiescent  period  (before 
the  onset  of  the  threatening  or  terminal  symptoms)  in  cases  of  persistent 
salpingitis,  appendicitis,  nephrolithiasis,  cholelithiasis,  and  many  other  ab- 
dominal and  pelvic  conditions  that  run  a  comparatively  rapid  course.  In  the 
case  of  a  patient  with  one  of  the  diseases,  the  prognosis  is  not  necessarily  fatal. 
Many  such  patients  having  persistent  symptoms  have  lived  to  old  age.  And 
yet  when  any  one  of  these  conditions  is  unmistakably  present,  and  there  are 
persistent  symptoms  from  it,  there  is  little  question  but  that  removal  of  the 
disease  is  the  part  of  wisdom,  not  so  much  because  the  present  symptoms  are 
troublesome  but  because  the  symptoms  indicate  that  the  process  is  contin- 
uing active — it  having  been  established,  and  generally  accepted,  that  when 
any  one  of  these  diseases  is  persistently  active,  it  is  liable  at  any  time  to  de- 
velop a  condition  that  may  cause  the  patient's  death  or  make  more  hazard- 
ous the  operation  then  necessary  to  save  her  from  death. 

"This  is  exactly  the  condition  that  is  present  in  uterine  fibromyoma 
with  persistent  symptoms,  even  though  the  symptoms  are  not  for  the  present 
threatening  or  disabling.  Yet  this  fact  is  not  generally  recognized,  and  there 
is  good  reason  for  its  not  being  recognized.  Physicians  generally  have  the 
excellent  habit   of  requiring  proof  before  accepting   a   statejnent,    and  the 


TREATMENT    OF   PIBROMYOMA  739 

absolute  proof  as  to  the  advisability  of  early  operation  in  uterine  fibromyoma 
has  not  been  forthcoming.  I  say  this  with  all  due  respect  to  the  many  ex- 
cellent men  who  have  expressed  as  many  excellent  variations  of  the  opinion 
that  early  operation  is  advisable.  Opinion  is  not  proof.  It  usually  precedes 
proof  and  stirs  up  and  brings  out  proof.  When  the  proof  is  produced,  how- 
ever, it  is  sometimes  found  that  the  opinion  which  preceded  it,  proceeded  in 
the  wrong  direction.  So  I  am  not  surprised  that  the  profession  waits  to  see 
the  proof,  before  accepting  the  statement  that  early  operation  should  be  the 
rule  in  these  cases. 

"When  we  come  to  produce  the  proof  we  find  that  we  haven't  it — at 
least,  if  any  one  has  it  I  have  not  seen  it,  and  I  have  spent  a  good  deal  of 
time  looking  for  it  in  the  last  few  years. 

"Facts  are  gradually  being  accumulated,  and  many  bearing  on  various 
phases  of  the  subject  have  already  been  presented  to  the  profession,  but  the 
actual  life  history  of  fibromyoma  patients,  of  the  class  under  consideration, 
has  not  been  followed  up  and  completely  recorded  in  a  sufficient  number  of 
cases  to  enable  us  to  present  positive  proof  as  to  what  proportion  of  them  die 
of  the  disease,  what  proportion  suffer  chronic  invalidism,  and  what  proportion 
experience  no  serious  trouble. 

"The  finding  of  fatal  complications  in  a  large  proportion  of  the  operated 
cases  is  not  proof  positive  that  the  less  severe  cases  should  be  subjected  to 
operation,  any  more  than  the  finding  of  perforation  or  abscess  formation  in  a 
large  proportion  of  the  severe  operated  cases  of  appendicitis  was  proof  posi- 
tive that  it  was  wise  to  subject  the  less  severe  cases  to  operation. 

"The  principal  question  concerning  these  fatal  complications  is  not  'What 
proportion  of  operated  cases  present  them?'  but  'What  proportion  of  the  mild 
cases  progress  to  them?' 

"I  do  not  minimize  the  importance  of  the  arduous  work  of  determining 
accurately  the  number  of  these  complications  in  operated  cases.  That  is 
needed  and  is  necessary  to  the  determination  of  the  proportion  of  serious  re- 
sults in  all  clinical  fibroid  cases. 

"But  in  our  enthusiasm  over  the  accomplishment  of  the  first,  we  must  not 
mistake  it  for  the  second.  The  proportion  of  operated  cases  presenting  these 
fatal  and  disabling,  complications  is  now  a  matter  of  record,  and  the  record 
includes  a  sufficiently  large  number  of  cases  to  justify  fairly  definite  conclu- 
sions on  that  point.  The  proportion  of  mild  cases  that  progress  to  the  serious 
condition  is  not  a  matter  of  record,  in  fact,  has  not  been  even  approximately 
determined,  and  can  not  be  until  the  life-history  of  a  very  large  series  of  the 
various  classes  of  fibromyoma  cases,  is  available  for  analysis. 

"This  can  be  secured  only  by  following  the  patients  of  each  class  through 
many  years  to  the  end.  No  doubt  this  matter  has  been  taken  up  to  some  ex- 
tent and  will  be  taken  up  very  generally  and  prosecuted  till  a  sufficiently  large 
series  has  been  secured.  I  hope  to  accumulate  some  information  on  this  point, 
at  least  for  my  own  satisfaction,  but  it  is  uphill  work.    The  patients  move  and 


740  NON-MALIGNANT   TUMORS   OF   UTERUS 

are  lost  sight  of.  There  is  not  the  same  mutual  interest  that  attaches  in 
operated  cases,  and  the  patients  are  followed  with  greater  difficulty  and  fewer 
returns.  But  this  life  history  of  the  less  severe  cases  can  be  obtained  in  time 
and  MUST  be  obtained,  for  it  is  necessary  to  complete  knowledge  of  the  subject. 

"Some  of  us  have  had  an  experience  in  these  cases  sufficiently  large  to 
justify  us  in  forming  and  expressing  an  opinion  to  assist  in  the  guidance  of 
others.  And  though  we  may  believe  that  our  views  are  sound  and  founded 
on  the  facts  as  far  as  they  go,  and  will  become  more  generally  recognized  as 
more  and  more  facts  are  established,  yet  we  must  not  forget  that  the  complete 
proofs,  in  black  and  white,  are  lacking  at  the  present  time. 

''Why  is  it  so  hard  to  establish  certainly  the  exact  proportion  of  fibro- 
myoma  cases  that  turn  out  badly?  Because  of  the  slow  progress  and  long 
duration  of  the  disease.  In  persistent  salpingitis  or  appendicitis  the  cases  that 
are  going  to  turn  out  badly  usually  do  so  within  one  or  two  or  three  years, 
so  by  watching  a  large  series  of  cases  for  that  length  of  time  it  could  be  de- 
termined what  proportion  resulted  seriously,  and  could  be  established  by  sta- 
tistical proof  just  what  proportion  of  cases  could  be  saved  from  death  or  dis- 
ablement by  early  operation.  The  fibromyoma  cases,  on  the  other  hand,  pre- 
sent  a  much  more  difficult  problem.  Here  the  absence  of  threatening  symp- 
toms for  five  or  ten  or  twenty  years,  gives  no  assurance  that  serious  trouble 
may  not  develop  at  any  time.  Case  histories  are  numerous  showing  that  pa- 
tients have  waited  patiently  and  hopefully  for  ten  or  twenty  years,  with 
fibroids  that  produced  no  serious  symptoms,  only  to  come  at  last  to  the  operat- 
ing table  because  of  some  rapidly  developing  trouble  dependent  on  the  tumor. 
Consequently  each  patient  must  be  followed  to  the  end  before  we  can  say  that 
there  was  no  occasion  for  removal  of  the  growth  in  that  case. 

"But  we  can  not  wait  until  all  these  things  are  determined  before  giving 
our  patient  advice. 

"What  are  the  facts  so  far  established,  that  will  help  to  guide  us  in  ad- 
vising this  patient  ? 

"1.  Some  fibromyomata  never  give  serious  trouble.  I  refer  of  course  to 
clinical  fibromyomata,  i.e.,  tumors  that  were  recognized  during  life  or  that 
could  have  been  recognized  had  the  patient  come  for  examination.  The  small 
latent  fibroid  nodules,  found  in  such  a  large  proportion  of  sectioned  uteri  re- 
moved postmortem,  are  not  now  under  consideration. 

' '  A  patient  may  go  through  a  long  and  useful  and  happy  life  with  a  pal- 
pable fibroid,  and  experience  no  particular  difficulty  from  the  growth.  This 
fact  has  been  demonstrated  over  and  over  again  in  clinical  work  and  in  au- 
topsies on  patients  who  have  died  of  independent  diseases  or  of  senility. 

"What  proportion  of  cases  run  this  course  we  do  not  know  either  exactly 
or  approximately.  We  know  only  that  'some' — a  considerable  number — have 
done  so.  This  fact,  however,  is  sufficient  to  overthrow  the  contention  that  'all 
palpable  fibroids  should  be  subjected  to  operation.'  The^re  is  a  mortality  due 
to  the  operation.    To  be  sure  the  mortality  is  small,  under  proper  technic  and 


TREATMENT    OF   FIBROMYOMA  741 

surroundings,  and  will  become  much,  smaller  as  the  cases  are  subjected  to 
operation  earlier  and  therefore  under  safer  conditions.  But  even  in  the  most 
favorable  cases  there  is,  and  will  continue  to  be,  an  occasional  death  from  the 
operation.  And  before  advising  operation  in  any  case  we  should,  as  already 
remarked,  assure  ourselves  that  the  chance  of  death  assumed  is  fully  justified 
by  the  danger  of  delay  in  that  particular  case. 

"2.  In  a  certain  proportion  of  cases  there  have  developed  fatal  complica- 
tions, which  were  due  to  the  tumor  or  would  haA'^e  been  prevented  by  its  early 
removal. 

''Just  what  proportion  of  all  clinical  fibroid  cases  have  developed,  or  Avill 
develop,  these  fatal  complications  we  do  not  knoAv,  and  can  not  know  in  the 
present  state  of  knowledge. 

''Just  what  proportion  of  operated  fibroid  cases  have  developed  these  com- 
plications has  been  determined  in  several  series  of  cases,  through  the  careful 
observation  and  painstaking  labor  of  the  physicians  under  whose  care  the  pa- 
tients came.  No  one  can  investigate  this  subject  without  coming  to  feel  under 
personal  obligation  to  the  men  who  have  taken  the  time  and  the  labor  to  prose- 
cute this  work  in  a  reliable  way  and  to  place  the  results  before  the  profession. 
To  Chas.  P.  Noble,  of  Philadelphia,  belongs  the  credit  of  stirring  up  the 
profession  on  this  subject,  by  presenting  and  keeping  before  it  incontestible 
evidence,  from  his  own  work  and  the  work  of  others,  of  the  great  frequency 
of  fatal  and  disabling  complications,  due  directly  to  these  tumors  or  asso- 
ciated with  them. 

"In  a  series  of  1,188  cases  collected  by  Noble  (Noble  278,  Seharlieb,  100, 
McDonald  280,  Martin  205,  CuUingworth  100,  Frederick  215,  Hunner  100), 
there  were  found  the  striking  number  of  795  complications. 

"However,  in  looking  over  this  list  it  is  seen  that  many  of  the  complica- 
tions are  not  serious  and,  of  even  the  serious  ones,  some  are  in  no  way  depend- 
ent on  the  presence  of  the  tumor. 

"In  order  to  determine  approximately  what  probable  fatalities,  here 
noted,  could  have  been  prevented  by  early  removal  of  the  growth,  I  prepared 
the  tabular  analysis  given  below. 

"The  number  of  tubal  and  ovarian  complications  prevented  by  early  removal  of  the 
growth  depends,  of  course,  on  the  number  of  tubes  and  ovaries  removed.  I  made  the  esti- 
mate on  the  basis  of  two-thirds  of  the  tubes  removed  (hysterectomy  in  two-thirds  of  the  cases 
and  myomectomy  in  one-third)  and  half  of  the  ovaries  removed  (both  ovaries  removed  in 
one-third  of  the  cases  and  one  ovary  removed  in  another  third).  Of  course,  if  found  advis- 
able to  limit  myomectomy  to  a  smaller  proportion  of  the  cases,  more  tubes  would  be  re- 
moved and  hence  more  tubal  complications  prevented. 

"As  to  whether  myomectomy  is  preferable  to  hysterectomy  in  a  considerable  propor- 
tion of  the  cases,  that  is  a  question  concerning  which  there  is  much  of  interest  to  be  said 
on  both  sides  and  it  can  not  be  taken  up  here.  However,  there  is  no  question  but  that, 
as  early  operation  is  more  widely  adopted,  a  larger  proportion  of  the  cases  will  be  found 
suitable  for  myomectomy.  In  fact,  the  more  frequent  saving  of  the  uterus  is  one  of  the 
benefits  that  will  follow  the  adoption  of  early  operation  in  these  cases.     The  chance  of 


742  NON-MALIGNANT   TUMORS   OF   UTERUS 

later  enlargement  of  small  'latent'  fibroid  nodules  to  the  dignity  of  clinical  fibroids,  is 
not  so  great  as  to  deter  us  in  preserving  the  uterus  in  suitable  eases.  Such  growth  takes 
place  occasionally.  Some  months  ago  I  was  obliged  to  remove  the  uterus  for  extensive 
multinodular  intraligamentary  fibroid  development  in  a  patient,  aged  31,  who  eighteen 
months  previously  had  undergone  myomectomy  in  a  New  York  hospital.  In  this  particular 
case  I  attribute  the  rapid  growth  of  the  fibroids  partly  to  the  chronic  congestion  of  a 
severe  pelvic  inflammation,  resulting  in  pyosalpins,  the  infection  evidently  having  been 
contracted  some  time  after  the  first  operation.  Ordinarily,  according  to  the  reported  cases 
that  have  so  far  come  to  my  notice,  this  development  of  other  tumors  after  operation  has 
not  taken  place  often  enough  to  constitute  a  serious  objection  to  myomectomy  in  suitable 
cases.  Again,  in  certain  cases,  the  preservation  of  the  uterus  is  well  worth  the  risk  of  a 
second  or  even  a  third  operation. 

"In  estimating  the  number  of  serious  tubal  and  ovarian  complications  prevented  by 
early  removal  of  the  tumor,  the  bare  proportion  of  tubes  and  ovaries  removed  does  not 
fully  represent  the  proportion  of  complications  prevented,  for  only  apparently  normal 
adnexa  are  left.  Those  tubes  and  ovaries  which  would  show  serious  trouble  later,  are 
likely  to  show  some  abnormality  at  the  time  of  operation  and  hence  would  be  removed. 

''The  table  includes  1,815  cases,  consisting  of  nine  series  of  consecutive  cases  (Noble 
1,118,  as  mentioned  above,  Watt-Keen  (from  Hofmeier's  clinic)  417,  Webster  210).  The 
question  is:  'What  probable  fatalities,  from  degeneration  of  the  tumor  or  from  local  com- 
plications, would  have  been  prevented  by  early  removal  of  the  tumor?,'  and  only  the 
complications  bearing  on  this  question  are  mentioned.  In  the  first  column  (A)  is  given  the 
number  found  of  the  particular  degeneration  mentioned.  In  the  second  column  (B)  is 
given  the  number  of  these  that  would  almost  certainly  have  been  prevented  by  the  early 
removal  of  the  tumor.  And  in  the  third  column  (C)  are  given  the  probable  fatalities  from 
the  latter. 

''Number  of  cases,  1815.  .ABC 

Necrosis  of  tumor 86  86  80 

Suppurating  tumor 10  10  8 

Edematous  tumor 11  H  4 

Myxomatous  degeneration  of  tumor 56  56  40 

Cystic  degeneration  of  tumor 53  53  30 

Calcareous  degeneration  of  tumor 36  36  6 

Serious  intralig.  development  of  tumor 44  44  15 

Malignant  disease  of  tumor  or  of  corpus  uteri 65  65  65 

Large  hydronephrosis  from  tumor  pressure 6  6  3 

Twisted  pedicle  of  tumor 33  3  2 

Pyosalpinx 37  24  15 

Salpingitis 127  84  12 

Abscess  of  ovary 10  5  3 

Carcinoma  of  ovary 3  2  2 

Ovarian  (cyst)  including  dermoids 118  75  60 

Probable  Fatalities 345 

''This  shows  probable  fatalities  numliering  345,  or  19  per  cent,  simply  from 
the  tumor  degenerations  and  local  complications  mentioned,  exclusive  of  other 


TREATMENT    OF    FIBROMYOMA  743 

fatal  and  disabling  effects  of  the  fibroid.  This  I  consider  an  nltraconservative 
estimate.  I  believe  that,  were  these  cases  traced  to  the  end  without  operation, 
the  number  of  deaths  simply  from  the  conditions  specified  would  considerably 
exceed  the  number  here  estimated. 

''In  a  recent  report  by  AYinter  of  753  operated  cases,  malignant  disease  of 
the  tumor  or  corpus  uteri  was  found  in  39  eases  and  total  necrosis  of  the  tumor 
in  17  cases.  Thus,  counting  only  two  of  the  serious  conditions  mentioned  in  the 
table,  it  is  found  that  they  include  nearly  8  per  cent  of  his  cases. 

[In  an  article  by  Noble  since  published,  in  which  he  analyzed  a  series  of 
2274  cases,  it  was  estimated  that  23  per  cent  of  the  patients  would  have  died, 
from  degenerations  or  complications  existing  in  the  uterus  or  in  the  appendages 
or  in  the  abdomen.  In  his  study  of  a  series  of  4480  cases  in  respect  to  car- 
cinoma, he  found  carcinoma  was  present  in  2.8%  (in  corpus  uteri  1.5%,  in 
cervix  1.29%).  In  a  careful  examination  of  his  own  337  consecutive  cases, 
hoAvever,  he  found  carcinoma  in  4%.  As  to  sarcoma,  Winter,  in  500  cases  in 
which  grossly  suspicious  areas  only  Avere  examined  microscopically,  found  sar- 
coma in  3.2%,  but  in  253  cases  sectioned  systematically,  sarcoma  was  found 
in  4.3 %i.  It  is  probal)le  then,  that  if  all  tumors  operated  on  late  Avere  sub- 
jected to  systematic  microscopic  examination,  malignant  disease  (sarcoma  or 
carcinoma)  would  be  found  in  8%.] 

"3.  In  a  certain  proportion  of  cases,  serious  visceral  degenerations  appear  in 
distant  organs.  The  frequent  association  of  heart  disturbance  with  advanced 
uterine  fibroid,  has  attracted  much  attention.  The  proportion  of  cases  show- 
ing heart  disturbance  is  striking.  AVinter  had  266  consecutive  cases  exam- 
ined for  heart  diseases  and  found  heart  disturbance  in  forty  per  cent.  In  five 
series  carefully  examined  (Winter  266,  Strassmann  and  Lehmann  71,  Boldt 
79,  Fleck  325,  Webster  210),  the  number  shoAA'ing  heart  disturbance  varied 
from  25  to  47  per  cent.,  aA'eraging  38  per  cent  for  the  AA^hole  951  cases.  Of 
course,  a  certain  number  of  these  heart  disturbances  Avould  haA'e  been  found 
in  any  series  of  patients.  But  making  due  alloAvance  for  these  the  number  is 
too  marked  and  constant  to  be  a  mere  coincidence.  The  exact  connection  be- 
tAveen  the  tAvo  has  not  been  Avorked  out.  But  AA'hether  the  heart  disturbances 
are  due  principally  to  the  chronic  anemia  from  hemorrhage  or  to  the  direct 
action  of  some  toxin  manufactured  in  the  fibroid,  or  constitute  simply  an  asso- 
ciated product  of  the  same  conditions  that  produced  the  fibroid — AA'hatever 
the  cause — the  fact  remains  that  they  are  there  and  must  be  reckoned  AA^th. 
Some  of  these  are  minor  functional  disturbances  but  on  the  other  hand  many 
are  of  serious  import. 

' '  That  such  is  the  ease  is  shoAvn  by  Baldy  from  the  records  of  the  Gynecian 
Hospital.  In  the  series  of  3,413  operations,  sudden  postoperative  death  due 
to  circulatory  disturbance  occurred  16  times.  Thirteen  of  these  sudden  deaths 
occurred  in  the  366  fibromyoma  cases,  AA'hile  the  3,047  other  operative  cases 
furnished  only  3  such  deaths.  It  occurred  36  times  as  frequently  in  the  fibroid 
cases  as  in  the  general  run  of  operative  cases. 


744  NON-MALIGNANT    TUMORS   OF    UTERUS 

''Other  visceral  degenerations  from  the  chronic  anemia,  from  pressure 
on  the  ureters  and  from  other  effects  of  the  fibroid,  produce  fatalities  due 
really  to  the  fibroid,  but  attributed  to  other  cases. 

''Let  us  now  look  at  some  of  the  facts  that  are  put  forward  against  the 
idea  that  myoma  causes  death  in  any  considerable  proportion  of  the  cases. 

"1.  General  mortuary  records  show  only  an  insignificant  death  rate  from 
this  disease. 

"The  U.  S.  Census  (1900)  shows  657  deaths  from  fibroid  tumor  of  the 
uterus  in  a  population  of  about  37,000,000  females. 

"The  Great  Britain  Census  (1901)  shows  339  deaths  from  fibroid  tumor 
of  the  uterus  in  a  poulation  of  about  17,000,000  females.  There  is  a  striking 
agreement  here,  both  indicating  that  the  death  rate  is  about  1  in  50,000 — a 
very  soothing  proposition  to  one  called  to  treat  a  patient  so  afflicted.  But 
are  these  all  the  deaths  from  fibroid  disease  in  that  time?  Do  not  the  numbers 
here  given  represent  simply  the  cases  in  which  nothing  else  could  be  found  to 
account  for  the  death?  How  about  the  fibromyoma  patients  that  died  of  kid- 
ney disease,  of  heart  disease,  of  anemia,  of  "uterine  hemorrhage,"  of  uterine 
"cancer"  (cancer  of  the  endometrium  associated  with  fibroid  or  a  sloughing 
fibroid  mistaken  for  cancer),  of  salpingitis,  of  peritonitis,  and  of  other  condi- 
tions due  directly  to  the  fibroid  or  that  would  have  been  prevented  by  its 
early  removal?  Until  we  count  the  deaths  due  to  these  complications,  the 
census  figures  amount  to  very  little  as  showing  the  deaths  due  to  fibroid  dis- 
ease. They  show  simply  that,  in  the  countries  mentioned,  few  patients  die 
of  uncomplicated  fibroids. 

"2.  Hospital  records  of  fibroid  cases  show  few  deaths  among  them.  In 
St.  Bartholomew's  Hospital,  among  547  uterine  fibromyoma  cases  there  were 
but  29  deaths,  and  28  of  these  followed  operations.  Here  is  a  series  of  547 
fibroid  cases  only  one  of  which  died  of  the  fibroid  while  28  died  of  the  opera- 
tions— accurate  records,  careful  diagnosis,  thoroughly  reliable  report.  What 
shall  be  said  to  that? 

"Before  deciding  as  to  the  practical  significance  of  these  figures  I  would 
seek  some  additional  information.  How  many  of  the  28  patients  who  died 
following  operation,  would  have  died  without  operation?  How  many  of  the 
547  patients  with  fibroid  tumors  were  saved  from  death  by  operation?  "What 
was  the  after-history  of  each  one  of  the  non-operated  cases.  When  this  ad- 
ditional information  is  obtained,  then  we  will  have  some  idea  as  to  how  many 
deaths  from  fibroid  would  have  occurred  without  operation  in  this  series  of 
547  cases. 

"Practically  the  same  deficiencies  appear  in  all  hospital  series  of  fibro- 
myoma cases,  and  in  a  measure  necessarily  so,  for  hospital  records  can  not 
show  the  number  of  non-operated  cases  that  come  to  death  or  operation  after 
they  leave  the  hospital. 

"3.  Large  series  of  cases  from  private  records  show  only  a  small  pro- 


TREATMENT   OF   FIBROMYOMA  745 

portion  of  the  patients  in  really  serions  condition.  There  are  many  such  re- 
ports. A  recent  one  is  that  of  E.  J.  Ill,  of  Buffalo,  in  which  he  reports  all 
fibroid  cases  seen  by  him  in  the  preceding  three  years.  There  Avere  300  cases. 
He  operated  on  53  and  advised  operation  in  6  others,  making  59  cases  in  which 
operation  was  required  according  to  the  indications  that  he  followed.  So  we 
have  here  a  large  series  of  fibromyoma  eases,  carefully  observed  and  reported, 
and  in  only  about  18  per  cent  was  'life  endangered'  or  'health  so  impaired 
that  life  was  a  burden.'  Eighteen  per  cent  of  serious  terminations  is  not  a 
small  per  cent  for  what  some  are  pleased  to  style  a  'harmless  growth.'  But  is 
that  the  total  number  of  serious  terminations  in  the  whole  300  cases?  How 
many  of  the  patients  who  were  in  good  condition  when  he  last  saw  them  will 
progress  to  the  same  stage  of  the  disease  in  which  he  saw  the  18  per  cent? 

"Fibromyoma  of  the  uterus  is  a  very  slow  growing  tumor.  It  maj^  gradu- 
ally progress  over  a  period  of  twenty  years  or  more.  Taking  off  the  first  five 
years,  as  the  tumor  may  not  come  under  observation  then,  we  have  fifteen 
years  of  the  growth's  progress  in  which  the  patient  is  likely  to  consult  a  phy- 
sician. If,  in  a  mixed  series  observed  during  a  period  of  three  years,  18  per 
cent  are  found  to  have  reached  the  serious  condition  mentioned,  what  per- 
centage will  have  reached  the  same  condition  when  the  same  series  has  been 
observed  six  years  or  nine  years  or  twelve  years  or  fifteen  years  ?  Of  course, 
it  would  not  be  true  to  assume  that  because  observation  of  the  series  for  three 
years  showed  serious  terminations  in  18  per  cent,  observation  of  the  same 
series  for  fifteen  years  would  show  serious  terminations  in  90  per  cent,  but 
it  would  be  much  nearer  the  truth  than  the  assumption  of  18  per  cent  as  the 
total  serious  terminations  in  the  300  eases. 

"Physicians  see  but  a  small  number  of  their  fibromyoma  cases  to  the  end. 
The  patient  in  the  earlier  stages  of  the  disease  drifts  from  one  physician  to 
another,  helping  to  swell  the  list  of  patients  'not  requiring  operation'  for  two 
or  three  or  more  physicians.  Later  there  develop  threatening  symptoms  de- 
manding operation,  which  is  carried  out.  In  the  records  of  the  last  physician 
only  does  the  case  appear  as  one  'requiring  operation.'  So  from  this  one 
case  there  would  be  statistical  proof  that  operation  is  required  in  only  33  per 
cent  of  fibroid  cases.     This  shows  how  easy  it  is  to  fall  into  serious  error. 

"In  looking  up  the  records  of  my  own  fibromyoma  cases,  in  hospital  and 
clinic  and  private  work,  I  find  that  171/^  per  cent  were  subjected  to  operation. 
Operation  was  advised  in  a  number  of  other  cases,  but  just  how  many  I  can 
not  state,  as  the  recommendations  were  not  always  recorded.  In  about  two- 
thirds  of  the  total  number  of  fibroid  cases  seen,  there  were,  at  the  time,  no 
urgent  or  threatening  symptoms.  But  I  do  not  deceive  myself  with  the  idea 
that,  because  these .  patients  were  in  fairly  good  condition  when  last  seen, 
they  should  therefore  be  classed  as  fibroid  cases  that  at  no  time  required 
operation.    They  could  not  properly  be  so  classed  until  traced  to  the  end. 

"Even  in  the  occasional  case  which  is  seen  through  all  stages  by  one 
physician,  the  progress  is  so  slow  and  the  last  stage  is  so  far  removed  from 


746  NON-MALIGNANT    TUMORS    OF    UTERUS 

the  first,  that  the  relation  of  cause  and  effect  is  in  a  measure  overlooked.  If 
the  end  came  in  two  or  three  years,  as  in  cancer,  it  would  be  impressive,  but 
the  first  appearance  of  the  tumor  and  the  ultimate  result  being  so  far  sepa- 
rated, the  connection  is  somehow  lost.  The  cost  seems  an  exceptional  one, 
some  new  factor  at  work — the  terminal  condition  can  hardly  be  recognized  as 
due  to  the  'harmless'  fibroid  which  the  patient  has  carried  so  many  years 
without  particular  trouble. 

"1  mention  these  things  because  I  believe  that  many  are  misled  by  them. 
The  latest  contribution  to  this  part  of  the  subject  that  has  come  to  my  notice, 
is  that  by  Thos.  Wilson,  of  Birmingham,  England.  He  assures  us,  on  practi- 
cally the  same  deceptive  evidence,  viz.,  the  analysis  of  a  series  of  cases  seen 
for  a  short  time,  that  of  fibroids  giving  rise  to  symptoms,  only  30  per  cent 
require  removal.  The  remaining  70  per  cent  require  merely  watching  and 
minor  palliative  treatment. 

''As  to  what  eventually  becomes  of  this  70  per  cent  he  furnishes  no 
proof.  However,  in  the  recommendations  for  the  care  of  them,  after  giving 
directions  for  the  relief  of  various  distressing  symptoms,  he  states,  'And,  fin- 
ally, operation  should  be  recommended  when  bleeding  gives  rise  to  anemia 
and  does  not  yield  to  ordinary  treatment ;  when  pain  is  severe  and  obstinate ; 
when  pressure  symptoms,  especially  retention  of  urine,  occur ;  when  the  tumor 
is  rapidly  increasing  in  size ;  and  generally  when  there  is  evidence  that  the 
health  of  the  patient  is  becoming  impaired' — and  he  might  have  added,  when 
the  kidneys  are  damaged;  when  the  cardio-vascular  system  is  seriously  af- 
fected; when  the  patient  is  in  bad  condition  for  operation;  and  when  the 
operative  mortality  is  necessarily  high.  I  fail  to  appreciate  the  advantages 
of  the  enumerated  conditions  secured  by  waiting. 

"I  am  anxious  to  get  at  the  real  significance  of  the  facts  presented  on 
this  subject.  I  am  not  interested  in  supporting  any  particular  theory.  I  have 
fibromyoma  cases  to  treat,  however,  and  I  want  to  know  what  is  best  for 
them,  and  do  not  intend  to  be  misled  in-the  matter,  one  way  or  another,  by 
taking  facts  to  mean  something  that  they  do  not  mean,  if  I  can  avoid  it.  I 
am  anxious  to  know  all  the  facts  against  early  operation  as  well  as  all  the 
facts  for  it.  I  would  gladly  welcome  any  information  establishing  the  safety 
of  waiting  in  these  cases,  for  no  one  feels,  more  than  I  do  the  responsibility 
of  advising  a  patient  in  comparatively  good  health  to  undergo  the  dangers  of 
a  serious  operation. 

"As  to  the  conclusions  in  this  matter,  I  would  urge  that  each  physician 
form  his  own  opinion  after  critical  consideration  of  established  facts — not 
hastily,  not  too  much  influenced  by  the  opinions  of  others,  but  carefully  and 
seriously,  as  one  who  is  personally  responsible  for  the  welfare  of  the  patient. 

"My  own  working  rules  in  this  matter,  are  as  follows: 

"1.  A  patient  who  has  a  small  fibroid  that  is  causing  no  symptoms,  re- 
quires no  treatment  for  the  fibroid.  Such  tumors  are  rarely  seen.  Occasion- 
ally one  is  discovered  in  the  course  of  an  examination  for  symptoms  plainly 


TREATMENT   OF   FIBROMYOMA  747 

due  to  other  cause.  In  sueli  a  case  I  usually  do  not  mention  to  the  patient 
that  she  has  a  fibroid,  unless  she  asks  directly  concerning  it,  though  I  take 
pains  to  state  the  fact  and  its  bearing  to  the  husband  or  other  responsible 
relative. 

"2.  A  patient  who  has  a  tumor  of  moderate  size,  causing  only  slightly 
troublesome  symptoms  which  may  yield  to  general  tonic  treatment  with  the 
addition  of  uterine  astringents  (ergotin,  stypticin),  is  put  on  that  treatment 
for  one  to  three  months — long  enough  to  satisfy  me  as  to  whether  the  symp- 
toms will  subside  under  this  treatment.  If  so,  the  treatment  is  continued  as 
necessary  to  control  the  symptoms.  By  'control'  of  the  symptoms  I  do  not 
mean  just  to  the  extent  that  the  patient  can  manage  to  get  along  as  a  semi- 
invalid,  but  to  such  an  extent  that  they  are  not  noticeable  to  her — that  she 
is  practically  a  well  woman. 

"If  I  find  the  symptoms  persist  after  a  satisfactory  trial  of  this  treat- 
ment, it  means  that  they  are  due  largely  to  the  activity  of  the  tumor,  and  not 
simply  to  the  accompanying  pelvic  congestion  (depending  principally  on  some 
minor  inflammatory  trouble  or  on  constipation  or  on  methods  of  work  or  on 
other  cause  independent  of  the  tumor).  The  persistence  of  symptoms,  after 
a  satisfactory  trial  of  the  measures  to  eliminate  symptoms  due  to  other  causes, 
means  that  the  tumor  itseK  is  already  an  active  irritant  in  the  pelvis.  Not 
active  in  the  sense  that  it  is  necessarily  rapidly  enlarging  or  degenerating,  but 
active  in  the  sense  that  it  has  not  passed  into  the  resting,  non-active,  clini- 
cally-cured state,  but  is  working  the  other  way.  It  is  active  in  the  same  sense 
that  a  persisting  appendicitis  is  active  in  the  quiescent  periods  between  the 
acute  attacks.  The  difference  is  that  the  activity  of  the  fibroid  is  more  in- 
sidious, less  disturbing  for  the  time  being,  slower,  not  published  by  acute 
exacerbations — but  nevertheless  persistently  progressive. 

''However,  before  recommending  operation  in  a  fibromyoma  case  because 
of  persistent  symptoms,  I  take  pains  to  make  certain  that  the  persistence  of 
the  symptoms  is  due  to  the  tumor,  and  not  to  some  associated  condition  or 
conditions  that  can  be  relieved  by  less  dangerous  measures. 

"Having  established  beyond  doubt  that  the  tumor  itself  is  already  a 
continual  irritant  in  the  pelvis,  I  say  to  the  patient  substantially  as  follows: 

"  'There  is  persistent  trouble  in  spite  of  the  treatment,  and  this  trouble 
is  due  to  the  tumor.  There  is  little  chance  of  its  getting  better  or  of  its  re- 
maining permanently  stationary.  The  strong  probability  is  that  it  will  get 
progressively  worse.  And  it  may  at  any  time  get  rapidly  worse,  and  develop 
conditions  that  would  increase  many  times  the  danger  of  the  operation  which 
would  then  be  necessary  to  save  your  life,  if  it  could  be  saved.  I  am  satis- 
fied that  the  danger  of  operation  now  is  much  less  than  the  danger  of  delay. ' 

"3.  In  cases  where  the  tumor  is  causing  symptoms  that  plainly  can  not 
be  corrected  by  other  measures,  I  at  once  recommend  operation,  without  wast- 
ing time  with  the^  other  measures. 


748  NON-MALIGNANT    TUMORS    OF    UTERUS 

''What  about  large  tumors  without  symptoms'?  I  am  skeptical  on  the 
subject  of  large  tumors  without  symptoms.  They  are  certainly  very  scarce. 
I  do  not  remember  having  seen  any  case  of  large  fibromyoma  in-  which  care- 
ful inquiry  did  not  show  some  evidence  of  disturbance  from  the  growth  be- 
fore it  had  attained  a  large  size— unless  the  following  case,  seen  recently 
in  consultation  could  be  classed  as  such. 

''The  patient,  a  white  woman,  aged  30,  unmarried,  noticed  in  a  casual 
way, .  about  the  middle  of  last  February,  that  the  lower  abdomen  seemed 
rather  larger  and  firm.  Subsequent  developments  indicate  that  the  tumor 
must  have  been  of  considerable  size  at  that  time,  probably  reaching  half  way 
to  the  umbilicus.  Careful  inquiry  elicited  no  noticeable  evidence  of  disturb- 
ance at  that  time,  not  even  bladder  irritation.  As  the  patient  felt  well  she 
paid  no  particular  attention  to  the  fullness  of  the  abdomen.  At  the  middle 
of  March  the  menstrual  floAv  was  not  so  free  as  usual  and,  for  reasons  best 
known  to  herself,  she  became  frightened  and  went  to  a  midwife  who,  March 
21,  introduced  a  sound  into  the  uterus  and  assured  the  patient  there  was  no 
pregnancy.  For  two  days  she  worked  and  felt  well.  The  second  night,  how- 
ever, she  had  a  chill  followed  by  fever  and  intermittent  pains  in  the  abdomen 
and  a  bloody  flow  with  clots.  The  trouble  increased  and  the  patient's  con- 
dition became  serious  and  she  called  in  Dr.  Max,  who  very  properly  pro- 
ceeded to  empty  the  infected  and  partly  emptied  uterus.  But  there  was  not 
much  material  to  be  removed.  The  fever  and  pains  kept  up  and  the  patient's 
condition  became  still  more  serious.  It  was  then  that  I  was  asked  to  see  her 
in  consultation.  Though  it  had  been  only  eight  days  since  the  onset  of  de- 
cided symptoms,  the  fibroid  uterus  was  then  as  high  as  the  umbilicus. 

"Thinking  that  possibly  the  acute  infection  was  of  such  character  that  it 
would  quickly  subside,  permitting  a  safer  operation  when  the  virulence  was 
spent,  we  treated  the  case  accordingly.  But  the  fever  continued  high,  the 
abdominal  pains  increased,  the  pulse  became  rapid  and  the  patient,  instead 
of  getting  better,  went  from  bad  to  worse.  So  we  were  obliged  to  operate, 
April  14,  in  the  presence  of  the  acute  infection.  The  specimen  furnishes  a 
particularly  clear  illustration  of  one  of  the  dangers  of  a  sloughing  fibroid,  so 
I  brought  it  for  your  inspection  (Figs.  616,  617).  The  necrotic  fibroid  has 
caused  a  perforation  through  the  uterine  wall  into  the  peritoneal  cavity. 

"This  was  one  of  those  mild  cases  that  'get  along  comfortably  and  pre- 
sent no  justification  for  subjecting  the  patient  to  the  risks  of  a  serious  opera- 
tion.' There  were  no  threatening  symptoms,  in  fact,  there  were  no  symp- 
toms of  any  kind  that  the  patient  had  noticed,  except  a  slight  fullness  in  the 
loM^er  abdomen.  And  yet  within  four  weeks  the  patient  was  in  a  most  seri- 
ous condition,  and  had  to  be  operated  on  in  that  condition  with  the  greatly 
increased  risk. 

"There  was  a  streptococcus  infection,  causing  sloughing  of  the  fibroid, 
and  the  large  sloughing  fibroid  had  caused  perforation  of  the  uterine  wall, 
destroying  an  area  as  large  as  a  silver  dollar,  as  here  shown.     The  omentum 


TREATMENT   OF   PIBROMYOMA  749 

was  adherent  over  this  opening.  When  the  adhesions  were  partially  separated 
the  bloody  infected  fluid  from  around  the  necrotic  fibroid  poured  out  into  the 
peritoneal  cavity.  This  gives  an  idea  of  the  desperate  character  of  the  case. 
The  operation  was  total  hysterectomy.  On  account  of  the  extensive  infec- 
tion, involving  the  peritoneal  cavity,  we  drained  freely  both  into  the  vagina 
and  through  the  abdominal  incision.  The  patient  recovered,  but  it  Avas  a 
close  call  for  her. 

''Returning  to  the  general  subject  of  advice  to  fibromyoma  patients,  the 
three  working  rules  just  given  very  readily  indicate  in  most  cases  whether 
the  tumor  should  be  let  alone  or  removed.  I  refer  to  the  general  run  of 
cases — the  common  forms  of  myoma  in  patients  under  ordinary  circumstances. 

' '  There  are,  of  course,  certain  exceptional  cases  in  which  there  must  be 
taken  into  consideration  special  conditions — in  the  fibromyomatous  uterus  or 
in  the  age  or  physical  condition  of  the  patient  or  in  her  surrounding  circum- 
stances. For  example,  if  the  uterus  is  pregnant  and  the  tumor  is  of  such 
size  and  situation  that  it  will  probably  not  interfere  with  pregnancy  and 
parturition,  I  would  not  interfere  at  that  time.  If  the  patient  is  in  the  meno- 
pause or  safely  through  that  period,  I  would  feel  justified  in  leaving  some  growths 
that  I  would  not  leave  in  a  younger  woman.  Again,  a  patient  may  be  in  circum- 
stances in  which  it  is  important  that  for  a  time  she  take  no  risk,  not  even  a  small 
one,  unless  absolutely  forced  into  it  by  the  most  threatening  conditions,  as  when 
she  has  small  children  wholly  dependent  on  her  for  the  time  being.  Again,  the  dis- 
tribution of  the  tumor  tissue  has,  in  certain  cases,  a  considerable  influence  on 
the  decision,  for  example,  a  patient  presenting  several  good-sized  nodules  in 
the  uterine  wall  can  wait  with  more  safety  than  where  the  same  amount  of 
fibromyomatous  growth  is  collected  in  one  or  two  large  tumors.  There  are 
many  such  special  conditions  that  must  be  taken  into  consideration.  This  is 
true  to  such  an  extent  that,  in  a  measure,  each  case  requires  particular  con- 
sideration and  decision.  This  is  the  reason  why  it  is  impossible  to  formulate 
rules  applicable  to  all  cases. 

''However,  we  necessarily,  even  in  the  exceptional  cases,  base  our  advice 
largely  on  some  general  guiding  principles.  And  it  behooves  us  to  be  certain 
that  those  general  principles  accord  with  the  facts  (the  real  facts  and  not 
the  supposed  facts)  as  far  as  the  facts  are  known. 

"In  closing  I  wish  to  emphasize  the  following  points: 

"1.  A  fibroid  tumor  of  the  uterus,  which  has  reached  a  size  to  be  ap- 
preciated clinically,  is  a  much  more  serious  affection  than  is  generally  sup- 
posed. 

"A  considerable  proportion  of  the  patients  develop  fatal  local  conditions, 
another  considerable,  proportion  develop  seriouy  distant  visceral  degenera- 
tions, and  a  large  proportion  of  the  remainder  (possibly  most  of  them)  finally 
pass  into  a  condition  of  chronic  suffering  and  invalidism. 

"2.  The  progress  of  the  disease  is  so  slow  as  to  be  deceptive,  many  cases 
taking  fifteen  \o  twenty  years  to  reach  full  development — hence  the  serious 


750  NON-MALIGNANT    TUMORS    OF   UTERUS 

results  do  not  appear  in  the  observation  of  a'  series  of  eases  for  a  few  years, 
a  few  years  constituting  but  a  fraction  of  the  developmental  period. 

"Yet  the  widespread  teaching  that  serious  conditions  develop  in  only  a 
very  small  proportion  of  the  eases,  is  based  largely  on  just  such  limited  ob- 
servations, recorded  and  unrecorded.  No  large  series  of  consecutive  cases 
followed  to  the  end  without  operation  has  shown  a  small  mortality. 

"3.  Uterine  fibroid  kills  principally  by  inducing  serious  local  and  gen- 
eral complications,  that  go  down  in  the  mortuary  records  as  the  cause  of 
death — hence  mortuary  records  give  no  indication  of  the  ravages  of  the  dis- 
ease.   It  kills  secretly  and  indirectly,  but  none  the  less  surely. 

"4.  The  proportion  of  the  various  classes  that  (a)  go  on  to  a  fatal  termina- 
tion or  (b)  become  chronic  sufferers  and  invalids  or  (c)  develop  no  serious 
symptoms,  can  be  exactly  determined  only  by  securing  accurate  records  of  a 
large  series  of  cases,  comprising  all  classes,  from  the  beginning  of  the  trouble 
to  the  end. 

''5.  Enough  is  already  known  to  show  that  delay  is  dangerous.  Many 
patients  develop  fatal  conditions,  many  find  operation  necessary  when  in  such 
a  state  as  to  make  the  operation  exceedingly  dangerous,  and  some  must  be 
refused  operation  because  of  advanced  complications — ^nearly  all  of  which 
loss  of  life  and  health  could  have  been  prevented  by  early  operation. 

"6.  The  chance  of  satisfactory  improvement  after  the  menopause  is, 
speaking  generally,  more  than  overbalanced  by  the  frequency  of  serious  de- 
generative changes  and  complications. 

''7.  We  assume  a  grave  responsibility  when  we  advise  a  patient  to  wait 
until  serious  symptoms  develop  before  having  the  tumor  removed. 

''Early  operation,  under  proper  conditions,  means  small  risk  to  the  pa- 
tient.   Late  operation  means  great  risk." 

PREGNANCY  AND  FIBROID 

The  association  of  fibromyoma  with  pregnancy  is  always  a  matter  for 
serious  concern,  though  many  patients  get  along  without  trouble.  Lafour,  in 
a  series  of  300  cases  of  fibroid  and  pregnancy  in  which  delivery  took  place 
by  way  of  the  birth  canal,  found  the  maternal  mortality  40  per  cent  and  the 
infantile  mortality  77  per  cent.  In  a  series  of  147  cases  of  fibroid  and  parturi- 
tion, collected  by  Susserott,  the  maternal  mortality  was  53  per  cent  and  the 
infantile  mortality  66  per  cent.  In  20  per  cent  of  these  cases  forceps  were 
used,  with  the  loss  of  8  mothers  and  13  children. 

Johnston  estimated  that  during  pregnancy  or  labor  one-third  of  the 
mothers  and  more  than  one-half  of  the  children  die,  and  recommends  celi- 
bacy when  the  tumor  can  not  be  removed.  Rosenwasser  said  in  1899  that 
antisepsis  and  improved  technic  had  reduced  the  maternal  mortality  only  to 
37  per  cent. 


PREGNANCY   AND   FIBROID  751 

Methods  of  Treatment 

1.  Non-interferenoe.  The  patient  is  allowed  to  go  along  until  term,  in 
the  hope  that  there  may  be  a  satisfactory  delivery  (spontaneous  or  operative). 
As  mentioned  later,  this  is  the  preferable  plan  in  many  cases.  The  results 
have  been  reported  in  various  series  of  eases,  as  follows : 

Spontaneous  Delivery.  In  a  series  of  84  cases  of  labor  complicated  by 
fibroids,  64  per  cent  of  the  patients  managed  to  deliver  themselves,  while  36 
per  cent  required  assistance  by  forceps  or  otherwise. 

Forceps.  In  Veit's  series  of  39  forceps  cases,  the  maternal  mortality  was 
33  per  cent  and  the  infantile  mortality  was  the  same. 

Version.  In  Veit's  series  of  87  version  cases,  the  maternal  mortality  was 
64  per  cent  and  the  infantile  mortality  82  per  cent. 

In  fibroid  cases  there  seems  to  be  a  marked  tendency  to  adherent  pla- 
centa. In  a  series  of  147  cases  of  fibroid  complicating  labor,  manual  removal 
of  the  placenta  was  necessary  in  21  cases,  and  13  of  these  women  died.  This 
serves  to  call  attention  to  the  difficulties  of  this  condition,  which  is  always  a 
serious  one  in  the  presence  of  a  fibroid. 

Caesarean  Section.  In  Saenger's  series  of  43  eases,  the  maternal  mortal- 
ity was  83.7  per  cent  and  in  Pozzi's  28  cases  the  maternal  mortality  was  86 
per  cent.  In  48  Porro  operations  in  fibroid  patients,  the  maternal  mortality 
was  33  per  cent.  In  a  later  series  of  49  cases  of  the  Porro  operation  in  fibroid 
patients,  the  maternal  mortality  was  only  12.5  per  cent,  showing  that  im- 
mediate removal  of  the  fibromyomatous  uterus  is  the  safe  operation.    • 

2.  Myomectomy.  The  patient  is  subjected  to  operation  for  the  removal 
of  the  tumor,  but  the  pregnancy  is  allowed  to  continue — if  it  will.  Leopold, 
in  his  myomectomies  in  the  pregnant  uterus,  from  1884  to  1894,  had  a  maternal 
mortality  of  17.4  per  cent  and  a  fetal  mortality  of  37.6  per  cent.  Stavely  had 
a  maternal  mortality  of  24.2  per  cent.  The  probability  of  abortion  is  great 
and  must  never  be  lost  sight  of,  though  many  cases  of  extensive  myomectomy 
have  recovered  without  abortion.  Olshausen  reported  21  myomectomies. 
Abortion  followed  in  38  per  cent.  In  a  series  of  57  myomectomies  and  enu- 
cleatioiis  during  pregnancy,  12  per  cent  of  the  women  died  and  24  per  cent 
aborted. 

3.  Hysterectomy.  The  fibromyomatous  uterus  is  removed  in  early  preg- 
nancy. In  a  recent  series  of  89  cases  of  supravaginal  hysterectomy  for  fibroid 
complicated  by  pregnancy,  the  mortality  was  11  per  cent.  When  the  opera- 
tion is  carried  out  promptly  (before  serious  complications  intervene)  the 
mortality  is  very  little  higher  than  hysterectomy  in  the  non-pregnant. 

4.  Induced  Abortion.  As  the  patient  is  in  a  serious  condition  and  her 
life  threatened,  the  plan  of  emptying  the  uterus  has  been  suggested  and  car- 
ried out.  Lafour  collected  39  cases  of  fibroid  and  pregnancy  in  which  this 
method  of  treatment  was  employed.    The  mortality  was  36  per  cent.    In  the 


752  NOX-MALIGXAXT    TUMORS    OF    UTERUS 

case  of  a  fibromyomatous  uterus  tlie  dangers  from  abortion  (spontaneous  or 
induced)  are  great,  because  of  the  difficulty  of  completely  emptying  the  uterus 

and  the  consequent  frequency  of  hemorrhage  and  sepsis. 

Selection  of  Treatment 

The  treatment  to  be  employed  depends  on  the  size  and  location  of  the 
fibromyoma  and  the  stage  of  pregnancy  at  ^vhich  the  patient  is  seen. 

When  the  tumor  is  in  the  upper  part  of  the  uterus  and  is  of  small  or 
]nedium  size  and  not  causing  much  trouble,  it  should  be  let  alone  until  after 
parturition. 

When  the  tumor  is  so  large  or  so  situated  (cei-vdx  fibroid)  that  it  pre- 
cludes the  possibility  or  probability  of  full-term  delivery  per  via  naturalis, 
the  treatment  turns  somewhat  on  the  stage  of  pregnancy.  If  the  patient  is 
seen  in  early  pregnancy,  hysterectomy  is  the  safest  plan  of  treatment.  In 
some  exceptional  eases  the  tumor  may  be  so  situated  that  myomectomy  (ab- 
dominal or  vaginal),  with  hope  of  continuing  the  pregnancy,  is  justifiable. 

If  the  patient  is  seen,  for  the  first  time,  in  late  pregnancy,  it  may  be  advis- 
able to  postpone  operation  imtil  full  term  or  nearly  full  term,  with  the  hope 
of  saving  the  child  by  Caesarean  section. 

Of  course,  there  are  all  gradations  in  seriousness,  from  the  cases  where 
it  is  almost  certain  that  there  will  be  no  trouble  to  the  cases  in  which  full- 
term  delivery  by  the  natural  route  would  be  absolutely  impossible.  It  is  the 
middle  class  that  contains  the  cases  that  furnish  the  most  puzzling  problems. 
When  seen  in  early  pregnancy  there  is  an  uncertain  factor,  namely,  the  prob- 
able extent  of  development  of  the  fibroid  during  pregnancy.  This  makes  it 
difficult  in  some  cases  to  decide  just  which  line  of  treatment  is  preferable. 
In  cases  of  doubt  after  giving  due  consideration  to  the  various  aspects  of  the 
case,  the  rule  is  to  await  developments. 

A  numerous  class  of  fibroid  cases  complicated  by  pregnancy,  is  that  in 
which  the  patient  has  one  or  more  fibroids  that  give  no  particular  trouble 
until  she  becomes  pregnant.  After  the  patient  has  been  pregnant  three  or 
four  months  the  symptoms  become  so  acute  and  threatening  that  the  tumor 
and  uterus  must  be  removed  or  the  uterus  must  be  emptied,  Avith  the  dangers 
incident  to  miscarriage  in  these  cases  (see  above)  and  the  probability  of  opera- 
tive removal  of  the  tumor  and  uterus  later.  Immediate  hysterectomy  is  the 
safest  plan  under  these  circumstances.  The  choice  of  the  treatment  in  such 
cases  is  discussed  in  detail  in  a  paper  read  by  the  author  before  the  St.  Louis 
Medical  Society  in  1901.* 


*Report  of  Two   Cases   of   Pregnancy   Requiring  Operation,   H.    S.    Crossen,   M.D.,    St.   Louis  Medical 
Review,   Aug.   24,    1901. 


PREGNANCY  AND  FIBROID 


753 


r  i  P  L—  —  ^~ll 


liv  t^ 


Fig.  623.  A  Lipoma  of  the  Posterior  Uterine  Wall.  Notice  the  cavity  of  the  uterus  running  along 
the  anterior  wall,  and  the  marked  thickening  of  the  endometrium  near  the  fundus.  This  is  an  exceedingly 
rare  form   of  uterine  tumor.      (Kno.K — Johns  Hopkins  Hosf'ita!  Bulletin.) 


754  NON-MALIGNANT    TUMORS    OF    UTERUS 

LIPOMA  OF  THE  UTERUS 

Lipoma  of  the  uterus  is  rare,  so  rare  as  to  constitute  a  curiosity.  A  few 
cases  have  been  reported,  one  of  which  is  shown  in  Fig.  623.  A  lipoma  in  the 
uterine  wall  may  come  without  particular  cause,  as  in  other  situations,  or  it 
may  come  from  fatty  degeneration  of  a  fibroid.  The  symptoms  and  treat- 
ment are  practically  the  same  as  for  fibromyoma.  The  exact  diagnosis  is 
made  after  the  mass  is  removed  and  laid  open. 


CHAPTER  IS 

MALIGNANT  DISEASE  OF  THE  UTERUS 

Malignant  disease  of  the  uterus  occurs  in  th^e  form  of  carcinoma  and  sarcoma. 
Carcinoma  of  the  cervix  uteri  is  so  different  clinically  from  carcinoma  of  the 
corpus  uteri,  that  it  seems  advisable  to  consider  the  two  separately.     The  sub- 
ject of  this  chapter  then  may  be  divided  into  three  parts,  as  follows : 
Carcinoma  of  the  Cervix  Uteri 

Squamous-cell  Carcinoma  (Epithelioma). 
Cylindrical-cell  Carcinoma  (Adenocarcinoma). 
Malignant  Adenoma. 
Endothelioma, 
Carcinoma  of  the  Corpus  Uteri 
Adenocarcinoma. 
Malignant  Adenoma. 
Endothelioma. 
Chorioepithelioma. 
Sarcoma  of  the  Uterus  (Cervix  and  Corpus) 

CARCINOMA  OF  THE  CERVIX  UTERI 

This  term  signifies  malignant  disease  of  epithelial  origin,  situated  in  the 
cervix.  It  may  arise  from  the  squamous  epithelium  covering  the  vaginal  sur- 
face of  the  cervix,  in  w^hich  case  it  is  a  squamous-cell  carcinoma  and  is  ordi- 
narily designated  as  ' '  epithelioma. ' '  It  may  arise  from  the  glandular  epithelium 
in  the  interior  of  the  cervix,  in  which  case  it  is  a  cylindrical  cell  carcinoma  and 
is  ordinarily  designated  as  "adenocarcinoma." 

Etiology 

The  cause  of  carcinoma,  as  of  other  forms  of  new  growth,  is  still  a  mystery. 
As  in  the  case  of  fibromyoma,  there  are  some  interesting  theories  but  they  are 
still  theories  only. 

Pathology- 
Cancer  of  the  uterus  is,  in  the  beginning,  essentially  a  local  process.    The 
apparently  independent  growths  appearing  later  in  various  organs,  are  simply 
metastases  from  the  primary  tumor.     This  fact  has  been  firmly  established  by 

755 


756 


MALIGNANT   DISEASE    OF    THE    UTERUS 


the  most  thorough  and  painstaking  investigation  by  many  authorities.  The 
supposition  that  it  is  simply  the  local  manifestation  of  some  constitutional  dys- 
crasia,  has  no  foundation.  The  important  bearing  of  this  on  treatment  is  apparent. 


/'f 


Fig.   624.     A  squamous-cell   cancer  in  its   early  stage  of  development  at  the  junction   of  the  stellate  tears   of 

the  cervix. 


Fig.   625.      Squamous-cell    Carcinoma    of    the    Cervix 
Uteri. 


Fig.   626.      Same  as  Fig.   625,   higher  power. 


Frequency.  As  far  as  known  at  present,  primary  carcinoma  occurs  more 
frequently  in  the  uterus  than  in  any  other  organ,  carcinoma  of  the  stomach 
coming  next  in  frequency.    Welch  found  in  a  series  comprising  31,000  carcinoma 


CARCINOMA   OF    THE    CERVIX   UTERI 


757 


cases  that  the  primary  growth  was  in  the  uterus  in  approximately  29  per  cent 
and  in  the  stomach  in  21  per  cent. 

Most  carcinomata  of  the  uterus  occur  in  the  cervix.  Cullen,  in  a  strict  analysis 
of  his  128  cases  of  carcinoma  of  the  uterus,  found  that  74  were  epitlieliomata  of 


Fig.  627.  A  carcinomatous  plug  growing  within 
a  cervical  gland,  the  walls  of  which  do  not  yet  show 
carcinomatous  change. 


Fig.  628.  Adenocarcinoma  of  the  cervix  uteri. 
This  section  is  from  the  growing  edge.  Notice 
normal  cells  and  carcinomatous  glands  in  the  same 
field. 


Fig.  629.     Adenocarcinoma  of  the  cervix  uteri.    Same   as  Fig.  628,  under  higher  power. 


758 


MALIGNANT   DISEASE    OF    THE   UTERUS 


the  cervix,  19  were  adenocarcinomata  of  the  cervix  and  35  were  adenocarcino- 
mata  of  the  corpus  uteri.  The  great  frequency  of  carcinoma  in  the  cervix  is 
supposed  to  be  due  largely  to  injuries  there  in  child-bearing,  with  resulting 
scar-tissue,  inflammation,  cystic  degeneration  and  chronic  irritation.  It  is  rare 
in  the  uninjured  cervix,  though  some  cases  have  been  reported,  even  in  children. 

Varieties.  Carcinoma  of  the  cervix  occurs  in  two  principal  forms — epithe- 
lioma (squamous-cell  cancer)  and  adenocarcinoma  (cylindrical-cell  cancer),  the 
epithelioma  being  by  far  the  more  frequent  (74  to  19  in  Cullen's  cases). 

Epithelioma  of  the  cervix  originates  from  the  squamous  epithelial  cells  cover- 


Fig.  630.     Advanced  stage  of  Cervical   Cancer   (Adienocarcinoma).     Only  a  small  portion  of  cervical   tissue 

can  be  seen  still  intact. 


ing  the  vaginal  portion.     Arising  from  that  part  of  the  cervix  known  as  the 
"portio  vaginalis,"  it  is  sometimes  spoken  of  as  ''cancer  of  the  portio." 

The  disease  begins  as  a  small  area  of  infiltration  on  the  vaginal  surface  of 
the  cervix,  supposedly  at  a  point  of  persistent  irritation  from  scar-tissue  or 
erosion  or  other  irritating  process.  If  the  patient  happens  to  be  examined  at 
this  stage,  the  infiltrated  spot  feels  rather  firm  to  the  touch.  That  is  all.  There 
is  no  pain,  there  may  be  no  bleeding  or  discharge,  though  there  may  be  some 
discharge  from  the  preceding  chronic  irritation.    So  far  as  the  naked-eye  appear- 


CARCINOMA   OF    THE    CERVIX   UTERI 


759 


aiice  is  concerned,  it  does  not  differ  materially  from  a  small  area  of  chronic 
inflammatory  infiltration  or  erosion.  The  essential  pathologic  change  is  that, 
at  the  point  indicated,  the  squamous  epithelium  is  beginning  to  penetrate  into 
the  underlying  connective  tissue  (Figs.  625,  626).  This  invasion  is  resisted  by 
the  leukocytes  which  collect  in  the  adjacent  tissue.  As  the  process  continues, 
the  carcinomatous  infiltration,  with  the  opposing  round  cell  (leukocyte  and 
lymphocyte)  infiltration,  penetrates  deeper  into  the  tissues  and  the  small  area 
of  induration  gradually  increases  in  extent.  A  small  abrasion  or  ulcer  appears 
(Figs.  624,  635,  636,  419).  This  usually  bleeds  slightly  when  touched.  Fre- 
quently the  first  evidence  of  anything  wrong  that  the  patient  notices,  is  a  slight 
streak  of  blood  or  spot  of  blood  after  coitus  or  after  extra  walking  or  other 


Fig.   631.      Cervical  Carcinoma  involving  only  one  lip,  forming  a  typical  papillary  growth. 


exertion.  This  may  remain  the  only  external  evidence  of  the  disease  for  many 
months — in  fact,  in  a  considerable  proportion  of  the  cases,  no  other  symptoms 
appear  until  the  disease  has  penetrated  deeply  into  the  cervix  and  out  into 
the  parametrium. 

As  the  disease  extends  in  the  cervix,  more  infiltration  becomes  appreciable  on 
palpation  and  more  ulceration  (which  may  be  mistaken  for  laceration  or  erosion) 
may  be  seen  through  the  speculum  (Figs.  421,  632). 

Still  later  there  may  be  ulceration  into  the  rectum  or  bladder  (Fig.  634), 
forming  fistulae  which  add  greatly  to  the  patient's  suffering. 

As  the  disease  advances,  projecting  growth  may  occur,  causing  distinct  papil- 
lary outgrowths  on  the  affected  portion  of  the  cervix  (Figs.  428,  631).    Still  later 


760 


MALIGNANT   DISEASE    OF    THE    UTERUS 


the  cervix  may  be  replaced  by  a  papillary  fungus  tumor-mass  (Figs.  630,  632). 
On  the  other  hand,  particularly  in  the  aged  with  very  slow-growing  epitheliomata, 
the  formation  of  contracting  scar-tissue  may  so  draw  in  the  affected  region  that  it 
can  not  be  seen.  In  such  a  case  it  can  be  appreciated  only  by  palpation,  which 
reveals  induration  at  the  vaginal  vault  (Fig.  422). 

In  addition  to  the  regular  and  essential  elements  of  the  diseased  tissue,  there 
may  be  secondary  changes.  Areas  of  softening  and  degeneration  occur  in  which 
the  cells  are  broken  down  and  become  simply  fluid  and  debris.  Hemorrhage  into 
certain  parts  of  the  growth  may  occur  and,  as  a  result  of  that  hemorrhage  there 


Fig.   632.     An  Epithelioma  of  the  Cervix  Uteri,  advanced  to  stage  of  the  destruction  of  tlie  cervix.      (Cullen — 

Cancer  of  the    Uterus.) 

remain  clots  and  discoloration  and  fluid.  Infection  may  take  place,  leading  to 
suppuration  or  sloughing.  Occasionally  lime  salts  are  deposited  in  the  cancer 
cells.  This  chalky  deposit  may  be  extensive  and  may  even  be  found  in  the 
metastases. 

Adenocarcinoma  of  the  cervix  arises  from  the  cylindrical  cells  lining  the 
interior  of  the  cervix  and  forming  the  cervical  glands.  It  may  then  in  the  begin- 
ning be  located  at  the  external  os  in  the  cervical  canal  or  in  any  part  of  a  gland 
extending  deeply  into  the  cervical  Avail  (Fig.  627) .    As  the  cell-columns  penetrate 


CARCrNOMA   OF    THE    CERVIX   UTERI 


761 


the  underlying  tissues,  the  cells  assume  somewhat  a  giand  formation  owing  to 
this  derivation  from  gland-forming  epithelium  (Figs.  628,  629).  This  gland 
formation,  however,  is  very  irregular  and  atypical,  being  represented  to  a  large 
extent  only  by  solid  columns  of  cells.  "Malignant  adenoma"  is  a  rare  form  of 
adenocarcinoma  in  which  the  penetrating  cells  preserve,  to  a  marked  extent,  the 
glandular  arrangement. 

The  intiltration  in  adenocarcinoma,  being  situated  in  the  interior  of  the 


Fig.  633.     Advanced  Adenocarcinoma   o£   the   Cervix  Uteri.      Notice    the   involvement   of   the   parametrium. 

(.KeWy— Operative  Gynecology.) 

cervix,  is  not  appreciated  by  the  examining  finger  until  a  considerable  mass  has 
formed.  The  disease  pursues  much  the  same  general  course  as  described  for 
epithelioma,  the  carcinoma  cells  penetrating  deeper  and  deeper  into  the  cervix 
and  into  the  surrounding  connective  tissue  (Fig.  633). 

Endothelioma  is  a  rare  form  of  malignant  disease  of  the  cervix  in  which 
microscopic  examination  shows  spaces  lined  wdth  proliferating  cells  resemblmg 


762 


MALIGNANT   DISEASE    OF    THE   UTERUS 


endothelium.  Its  exact  nature  and  origin  have  not  been  determined — in  fact,  it 
is  still  uncertain  whether  it  is  an  epithelial  growth  (carcinoma)  or  a  connective- 
tissue  growth  (sarcoma). 

Modes  of  Extension.  Carcinoma  of  the  cervix  extends  in  four  ways — by 
continuity  of  tissue,  by  lymphatics,  by  the  blood  stream  and  by  implantation. 

Extension  by  continuity  of  tissue  is  the  principal  method  and,  aside  from 
exceptional  cases,  the  only  method  in  the  earlier  stages  of  the  growth.  In  this 
method  of  extension,  the  carcinoma  cells  grow  into  the  tissues  against  which  they 
lie.    This  differs  markedly  from  the  way  in  which  a  non-malignant  tumor  extends 


Fig.   634.     An  Epithelioma  of  the  Cervix  Uteri,  still  farther  advanced.     The  growth  has  invaded  the  bladder 
and  rectum,  causing  fistulae  into  these  organs.     (Cullen — Cancer  of  the   Uterus.) 

(Fig.  639).  A  fibromyoma  as  it  grows,  pushes  aside  the  adjacent  tissues,  but  a 
malignant  tumor  as  it  grows  penetrates  the  adjacent  tissues  and  destroys  them. 
It  is  this  insidious  involvement  of  the  contiguous  tissues  that  makes  many 
cervical  carcinomata  inoperable  when  first  seen.  It  is  this  same  gradual  extension 
outward  by  continuity  of  tissue  that  later  causes  the  patient  most  of  her  suf- 
fering and  that  in  most  cases  causes  her  death,  by  involving  the  uterus  or 
bladder  or  rectum. 

In  extension  through  the  lymphatics,  some  carcinoma  cells  are  caught  in 
the  lymph  current  and  carried  to  lymphatic  glands,  where  they  lodge  and  grow 


CAECINOMA   OF    THE    CERVIX   UTERI 


763 


and  destroy  tissue  tlie  same  as  the  parent  growth.  This  invasion  of  the  lym- 
phatic glands  by  carcinoma  cells  does  not  occur  usually  until  rather  late  in  the 
disease — until  it  has  extended  by  continuity  of  tissue  through  the  cervix  into 
the  parametrium. 

Winter  found  cancerous  glands  in  only  2  cases  in  44  autopsies  on  patients 
where  the  disease  was  confined  to  the  uterus.  "Wertheim,  in  60  operated  cases, 
found  involvement  of  removed  glands  in  15  per  cent  of  early  cases  and  in  31.7 


Fig.  63S.  A  Small  Epithelioma  of  the  Cervix  Associated  with  Fibromyoma  of  the  Corpus  Uteri. 
In  this  case  the  most  evident  lesion  was  the  fibroid,  but  further  examination  revealed  induration  and 
irregularity  about  the  external  os,  with  some  bleeding  on  examination.  A  piece  of  tissue  excised  from  the 
suspicious  area  and  submitted  to  microscopic  examination  showed  epithelioma.  The  specimen  is  shown 
sectioned  in  Fig.  636. 

per  cent  of  all  cases.  Schauta  made  a  most  thorough  autopsy-study  of  60  cases, 
in  40  of  which  the  patients  died  from  the  natural  effects  of  the  cancer  and  in 
9  from  intercurrent  affections.  In  43.3  per  cent  of  the  whole  series,  the  glands 
w^ere  entirely  free  of  carcinomatous  metastases.  The  lower  (removable)  glands 
alone  were  involved  in  13.3  per  cent,  the  upper  (not  removable)  glands  alone 
in  8.3  per  cent  and  both  lower  and  upper  glands  in  35  per  cent. 


764 


MALIGNANT   DISEASE    OP    THE    UTERUS 


Kundrat,  in  a  study  of  76  cases  operated  on  by  Wertheim,  in  which  the 
parametrium  was  involved  on  one  or  both  sides,  found  the  glands  entirely  free 
of  metastases  in  71  per  cent.  The  glands  on  one  side  were  involved  in  22  per 
cent,  and  the  glands  on  both  sides  were  involved  in  7  per  cent. 

The  glands  are  rarely  involved  until  the  cancer  has  advanced  into  the 
parametrium.  Kundrat,  in  his  analysis  of  80  eases,  found  only  four  in  which 
the  glands  were  involved  with  the  parametrium  free. 

Enlargement  of  the  regional  glands  is  very  common  in  the  early  stage  of 
carcijioma  but  this  enlargement  is,  as  a  rule,  not  due  to  carcinoma  cells  but  to 


Fig.  636. 


An  Antero-posterior  Section  of  the  specimen  shown  in  Fig.  635.     Microscopic  examination  showed 
that  the  epithelioma  extended  along  the  cervical  canal  practically  to  the  internal  os. 


the  inflammatory  hypertrophy  that  nearly  always  takes  place  in  the  glands 
draining  a  region  that  is  subject  to  severe  chronic  irritation.  In  exceptional 
cases,  hoAvever,  the  glands  may  become  infected  with  carcinoma  cells  at  an  early 
stage  of  the  disease. 

This  matter  of  glandular  involvement  has  a  very  important  bearing  on  the 
question  of  operative  treatment. 

In  extension  by  the  blood  stream,  some  carcinoma  cells  penetrate  into  a 
blood  vessel,  are  caught  in  the  current  and  are  carried  to  distant  organs,  where 
they  lodge  and  grow  and  form  metastatic  tumors.    In  whatever  kind  of  tissue 


CAECIXO:\IA   OF    THE    CER\aX   UTERI 


765 


these  metastatic  growths  are  situated,  they  reproduce  the  structure  of  the 
parent  growth.  The  lungs  are  most  frequently  affected,  though  there  are  many 
other  organs  that  are  affected  occasionally.  The  possibility  of  metastases  must 
be  kept  in  mind  in  deciding  whether  or  not  a  case  is  operable.  If  metastasis  to 
distant  organs  has  occurred,  hysterectomy  would  of  course  be  useless,  except 
as  a  palliative  measure.  However,  such  metastases  almost  never  occur  except 
in  the  last  stage,  and  then  not  very  frequently.  AVinter.  in  202  cases,  found 
metastases  in  distant  organs  in  only  210  per  cent. 


Fig.   637 


Dilatation  of  the  Ureters  and  Kidneys,  due  to  obstruction  of  the  ureters  bj-  Cancer  of  the  Cervix 
Uteri.      (Kelly — Operative   Gynecology.} 


Direct  Implantation  of  cancer  cells  into  the  healthy  tissues  of  a  raw  surface 
takes  place  principally  in  operations  for  cancer — the  cells  being  carried  on  the 
knife  or  scissors  or  other  instrument,  or  on  the  fingers  or  sponges,  from  the  infil- 
trated area  to  the  healthy  tissue  which  has  been  laid  open  in  the  operative 
work.  Many  undoubted  instances  of  this  occurrence  are  on  record.  It  fur- 
nishes a  strong  reason  for  keeping  entirely  clear  of  the  involved  area  in  opera- 
tions for  the  cure  of  cancer. 


766,  MALIGNANT   DISEASE   OF    THE    UTERUS 

Complications.  Aside  from  the  tumor  itself,  there  are  several  conditions 
resulting  from  it  that  enter  into  the  pathologic  and  clinical  picture.  The 
ureters  may  be  compressed,  leading  to  dilatation  of  the  ureters  and  also  to 
hydronephrosis  (Fig.  637).  In  the  later  stages  there  is  compression  of  the  pel- 
vic nerves  and  vessels,  causing  pains  and  edema.  The  infiltration  may  penetrate 
the  wall  of  the  bladder  or  rectum,  and  if  the  infiltrated  tissues  break  down, 
fistulae  into  these  organs  are  formed  (Fig.  634). 

Associated  Diseases  also  add  to  the  pathologic  picture  in  certain  cases. 
Fibromyoma  of  the  uterus  is  a  rather  frequent  association  (Figs.  897,  635).  Va- 
rious inflammatory  lesions  are  frequent  and  add  much  to  the  danger  and  dif- 
ficulties of  operative  treatment. 

Duration  of  the  Disease.  This  is  variable,  the  limits  ordinarily  being  one 
to  three  years.  The  duration  depends  somewhat  on  the  kind  of  tumor  (the 
softer  the  tumor  the  more  rapid  the  growth),  upon  the  age  of  the  patient  (the 
younger  the  patient  the  more  rapid  the  growth)  and  upon  the  proximity  to 
childbirth — -those  carcinomata  appearing  within  one  year  after  parturition 
progressing  very  rapidly. 

These  are  only  general  rules,  to  which  there  are,  of  course,  exceptions. 

Effect  of  Pregnancy.  Sometimes  carcinoma  of  the  cervix  may  appear 
while  the  patient  is  pregnant,  or  occasionally  pregnancy  may  take  place  in 
the  early  stage  of  carcinoma  of  the  cervix.  In  either  case  the  effect  of  preg- 
nancy is  to  hasten  the  progress  of  the  carcinoma.  The  softening  of  the  tissues 
and  the  congestion  associated  with  pregnancy,  seem  to  favor  rapid  extension 
of  the  malignant  disease. 


Symptoms  and  Diagnosis 

The  first  symptom,  in  practically  all  cases  of  carcinoma  of  the  cervix  is  a 
slight  leucorrheal  discharge,  with  an  occasional  spot  of  blood.  This  slight 
streak  of  blood  is  seen  usually  after  extra  exertion  (extra  work,  long  walk, 
lifting)  or  after  a  douche  or  after  coitus.  It  is  especially  liable  to  appear 
within  24  hours  after  coitus.  A  history  of  such  ''spotting"  of  the  discharge 
or  of  the  clothing,  calls  for  a  most  careful  examination,  that  the  presence  or 
absence  of  carcinoma  of  the  vaginal  surface  of  the  cervix  or  of  the  interior  of 
the  cervix,  may  be  certainly  determined. 

In  giving  the  symptoms  and  the  diagnosis  of  this  disease,  it  is  preferable  to 
speak  nearly  altogether  of  the  early  stage.  It  is  in  this  stage  that  the  diagnosis 
is  most  difficult  and  it  is  in  this  stage  that  the  diagnosis  is  most  important,  for 
operation  then  will,  in  a  large  proportion  of  the  cases,  save  the  life  of  the 
patient.  In  this  connection  it  will  be  an  advantage  to  consider  the  differ- 
ential diagnosis  between  the  early  stage  of  malignant  disease  of  the  uterus  in 
general  (both  carcinoma  and  sarcoma)  and  the  conditions  with  which  it  is  likely 
to  be  confused.     This  is  a  very  important  subject,  particularly  to  the  general 


CARCINOMA   OF    THE    CERVIX   UTERI  767 

practitioner  who  usually  sees  the  patient  first  and  upon  whom  rests  the  respon- 
sibility of  recognizing  malignant  disease  in  its  beginning,  or  of  recognizing 
the  cases  in  which  it  may  be  present  and  which  require'  special  investigation 
accordingly. 

Concerning  early  diagnosis  of  malignant  disease  of  the  uterus,  the  author 
will  quote  from  a  paper  published  in  1900  :* 

''How,  then,  are  we  to  discharge  our  responsibilities  in  this  matter?  We 
can  not  cure  every  woman  who  comes  to  us,  nor  excise  and  examine  a  piece 
of  the  cervix,  simply  because  she  might  have  cancer. 

"What  is  needed  is  the  adoption  of  a  practical  mode  of  procedure  for 
determining  certainly,  in  patients  with  uterine  disease,  whether  or  not  malig- 
nant infiltration  is  present. 

"Malignant  disease  of  the  uterus  means  carcinoma  or  sarcoma.  Carci- 
noma may  start  from  the  squamous  epithelium  covering  the  cervix  or  from  the 
cylindrical  epithelium  lining  the  canal  of  the  cervix  and  body  of  the  uterus  or 
from  the  gland-cells  situated  deeply  in  the  substance  of  the  cervix  and  body. 
Sarcoma  may  start  from  any  part  of  the  organ. 

"Malignant  trouble  is  invariably  chronic  and  there  is  always  present 
either  induration  or  ulceration. 

"In  the  CERVIX,  if  there  is  induration  it  can  be  felt.  If  there  is  ulcera- 
tion or  erosion  of  the  outer  surface  of  the  cervix,  it  can  be  seen.  If  there  is 
ulceration  within  the  cervical  canal,  it  will  cause  a  troublesome  discharge.     . 

"In  the  BODY  of  the  uterus,  if  there  is  ulceration  it  will  cause  a  troublesome 
discharge.  By  'troublesome  discharge'  I  mean  what  is  ordinarily  called  'leucor- 
rhea' — ^not  the  watery  discharge  of  advanced  cancer.  Induration  in  the 
body  of  the  uterus  can  not,  of  course,  be  detected,  until  a  considerable  mass 
has  formed.  I  am  satisfied,  however,  that  practically  every  case  of  malig- 
nant disease  of  the  body  of  the  uterus,  whether  carcinoma  or  sarcoma,  presents 
a  discharge  while  the  infiltration  is  still  in  an  early  stage — that  is,  before  it 
has  gone  beyond  the  reach  of  radical  operation. 

"In  forming  a  conclusion  as  to  whether  or  not  a  lesion  is  malignant,  we 
should  not  give  too  much  weight  to  the  youth  of  the  patient.  To  be  sure,  in 
carcinoma  the  patient  is  usually  past  thirty-five.  But  carcinoma  may  occur 
before  thirty.  One  patient  for  whom  I  did  an  abdominal  hysterectomy  for 
carcinoma  was  but  twenty-eight  and  the  disease  had  then  been  present  long 
enough  to  form  a  large  mass  and  had  been  giving  her  much  trouble  for  sev- 
eral months.  Several  cases  of  this  disease  in  patients  under  twenty  have 
been  reported.    Sarcoma  may  develop  at  any  age. 

"Called  to  see  a  patient  with  pelvic  disease,  if  there  is  no  erosion  or  ulcer- 
ation of  the  cervix,  no  induration  of  the  cervix  or  body  of  the  uterus,  and  no 
chronic  pathologic  discharge,  "we  are  safe  in  assuming  that  the  uterus  is  free 


*Early  Recognition  of  Uterine  Cancer,  H.   S.   Crossen,  M.D.,  St.   Louis  Courier  of  Medicine,  1900. 


768  :^IALIGXAKT   DISEASE    OF    THE   UTERUS 

from  malignant  trouble.  AVhen  any  of  these  signs  are  present  we  must  make 
a  differential  diagnosis. 

"Induration  in  the  Cervix.  Induration  in  the  cervix  may  be  due  to  cystic 
disease  or  to  sear-tissue  from  laceration  or  to  a  fibroid  or  to  malignant  disease. 

"In  cystic  disease,  if  the  nodule  be  punctured  and  then  pressed  upon  the 
characteristic  clear  glairy  substance  will  be  extruded  and  the  induration  Avill 
largely  disappear.  If  there  remains  enough  induration  to  make  the  diagnosis 
doubtful,  excise  a  small  wedge-shaped  j)iece  and  submit  it  to  a  pathologist 
for  examination. 

"In  scar-tissue  from  laceration,  the  induration  is  limited  to  the  site  of 
injury  and  the  cause  is  plain.  Also  in  scar-tissue  the  area  of  induration  re- 
mains practically  the  same,  whereas  if  malignant  the  area  of  induration 
gradually  increases.  In  this  case,  as  in  every  other,  if  there  is  reasonable 
doubt  after  a  short  period  of  careful  observation,  excise  a  piece  for  microscopic 
examination. 

"In  fibromyoma  of  the  cervix,  fibroids  elsewhere  in  the  uterus  may  often 
be  detected,  making  it  probable  that  the  nodule  in  the  cervix  is  similar  in 
nature.  A  well-marked  tumor  of  the  cervix,  even  a  fibromyoma,  should  be 
removed,  for  almost  without  exception  a  fibroid  in  that  situation  causes 
very  troublesome  symptoms.  A  small  mass  with  no  fibroids  elsewhere  should 
have  a  piece  excised  to  make,  certain  the  diagnosis. 

"Ulcer  or  Erosion  on  Cervix.  An  ulcer  or  a  spot  of  erosion  on  the  cervix 
may  be  due  to  an  irritating  discharge,  to  a  pessary  or  other  irritant,  to  eversion 
of  the  mucous  membrane  by  laceration,  or  to  tuberculosis,  syphilis,  chancroid 
or  cancer.  In  the  first  two  mentioned  the  lesion  heals  promi^tly  on  removing 
the  cause. 

"Where  the  cervix  is  torn  so  deeply  that  the  mucous  membrane  is  everted 
and  granulating,  the  cervix  should  be  repaired,  and  the  tissue  removed  in  the 
denudation  for  repair  may  be  examined  microscopically.  If  there  is  no  malig- 
nant trouble,  the  cervix  will  be  in  much  better  condition  than  before,  and  we 
will  have  satisfied  ourselves  that  it  was  only  simple  trouble  and  the  patient 
need  never  know  that  there  was  a  suspicion  of  malignancy.  If  malignant 
infiltration  is  found  in  the  excised  tissue  the  uterus  can  be  removed  at  once 
Avith  the  probability  of  a  permanent  cure. 

"Tubercular  Ulceration  of  the  cervix  is  rare.  The  diagnosis  is  made 
from  microscopic  examination  of  pus  and  scrapings  from  the  diseased  area. 

"In  Syphilitic  Ulceration  there  are  usually  other  lesions  or  a  history  Avhich 
makes  the  diagnosis  clear.  Furthermore,  a  syphilitic  lesion  of  the  cervix, 
Avhether  primary,  secondary  or  tertiary,  should  jdeld  within  a  reasonable  time 
to  appropriate  treatment,  provided  the  patient's  general  health  is  not  too 
much  depressed. 

"Chancroidal  Ulceration,  which  is  thoroughly  cauterized,  should  within  a 
short  time  thereafter  show  healthy  granulation  and  rapid  healing.     A  sore 


CAKCINOMA   OF    THE    CERVIX   UTERI  769 

on  the  cervix  that  resists  appropriate  treatment  should  have  a  piece  removed 
for  examination. 

"The  foUoAving  method  of  differential  diagnosis  has  been  proposed:  Soak 
a  pledget  of  cotton  in  10  per  cent  copper  sulphate  solution  and  apply  it,  for 
a  minute  or  two,  to  the  suspicious  surface.  If  the  lesion  is  a  simple  erosion, 
a  bluish-white  coating  will  form  without  hemorrhage.  By  repeating  the 
application  at  intervals  of  three  or  four  days  the  erosion  will  soon  be  healed. 
If  the  lesion  is  an  ectropion  it  will  be  blanched  by  the  application.  If  the 
lesion  is  cancerous  ulceration,  the  copper  sulphate  application  will  cause 
bleeding.  A  few  days  later  another  application  is  made,  and  if  the  bleeding 
is  more  free,  the  diagnosis  of  incipient  carcinoma  is  almost  certainly  correct. 
Heitzman,  who  brings  forward  this  method,  states  that  he  rarely  failed  to 
find  microscopic  confirmation  of  this  provisional  diagnosis.  In  all  ulcerations 
except  malignant,  the  bleeding  is  checked  by  a  few  applications  of  copper  sul- 
phate in  solution,  and  the  persistence  of  a  single  bleeding  point  after  the 
rest  of  the  raw  surface  is  healed  indicates  malignancy  and  calls  for  a  micro- 
scopic examination  of  tissue  from  the  suspected  area. 

"Discharge  From  the  Uterus.  There  still  remains  for  differential  diag- 
nosis the  diseases  causing  uterine  discharge,  and  here  is  where  the  difficulties 
begin  and  where  there  have  been  so  many  failures.  I  say  'many  failures,'  for 
of  the  hundreds  of  women  who  die  annually  of  cancer  of  the  uterus,  I  believe 
a  large  number  go  to  physicians  in  the  early  stages  and  are  treated  for 
chronic  endometritis. 

"Taking  up  the  differential  diagnosis,  we  know  that  malignant  disease 
is  always  chronic.  So  we  can  eliminate  at  once  all  the  acute  diseases,  leaving 
only  the  following:  Chronic  endocervicitis  (septic,  gonorrheal,  and  glandu- 
lar), CHRONIC  endometritis  (simple,  septic,  gonorrheal  and  tubercular),  Polypi 

and  FIBROMYOMATA. 

"In  differentiating  these  affections  from  malignant  trouble,  the  effect  of 
treatment  is  an  important  item.  Inflammation  of  the  uterus  in  any  form  is 
greatly  benefited  by  appropriate  treatment.  Consequently  every  case  of 
uterine  disease  presenting  induration,  ulceration,  or  discharge,  should  be  sub- 
jected to  careful  and  vigorous  treatment  for  the  purpose  of  differential  diag- 
nosis as  well  as  for  the  purpose  of  effecting  a  cure. 

"Chronic  Endocervicitis.  In  suspected  chronic  endocervicitis,  a  very 
good  plan  is  to  give  a  hot  antiseptic  douche  two  or  three  times  daily,  and 
every  second  or  third  day  apply  a  4  per  cent  silver  nitrate  solution,  or  tincture 
of  iodine,  to  the  cervical  canal.  If  there  is  a  marked  congestion  of  the  cervix, 
make  multiple  punctures.  If  the  external  os  is  so  small  as  to  interfere  with 
drainage,  open  it  by  dilatation  or  incision.  If  there  are  cysts,  puncture  and 
evacuate  them  and  touch  the  cavities  with  silver  nitrate  or  tincture  of  iodine 
or  carbolic  acid.  If  there  are  polypi,  remove  them.  If  the  cervix  is  hypertro- 
phied  and  riddled  with  cyst,  excise  most  of  the  diseased  area  and  repair  the 
cervix  or  partially  amputate  it. 


770  MALTGXAXT   DISEASE    OF    THE    UTERUS 

"Ally  tissue  removed  from  the  cervix,  eitlier  curettings  or  polypi  or  pieces 
removed  in  denudation  for  repair,  should  be  subjected  to  a  microscopic  exam- 
ination m  every  case  that  is  the  least  suspicious.  The  simple  fact  that  cystic 
disease  is  present  does  not  exclude  cancer.  Both  may  be  present,  and  if  the 
pathologic  discharge  persists  after  a  course  of  treatment,  a  piece  should  be 
excised  from  the  suspicious  area. 

"Chronic  Endometritis.  Simple  endometritis — ^that  is.  where  there  is 
no  pus  infection — is  due  usually  to  poor  blood  or  a  malposition  or  a  stenosis 
or  subinvolution  or  a  tumor.  Eemove  the  cause,  and.  if  the  changes  in  the 
endometrium  are  not  marked,  they  vill  subside  spontaneously  or  after  a 
few  astringent  applications.  If  the  pathologic  changes  are  marked,  it  is 
not  sufficient  to  remove  the  cause  but  ve  must  remove  also  the  diseased 
endometrium,  that  a  nev  and  better  one  may  develop  under  the  bettered 
conditions.  If  the  case  is  not  perfectly  plain,  the  scrapings  should  be  ex- 
amined microscopically  that   the  diagnosis  may  be   confirmed   or   disproved. 

"In  chronic  septic  endometritis  and  in  chronic  gonorrheal  endometritis, 
the  idea  of  effecting  a  cure  by  long-continued  intrauterine  applications,  re- 
peated week  after  week  and  month  after  month,  is  a  delusion  and  a  snare. 
These  long-continued  applications  rarely  if  ever  effect  a  cure,  they  frec[uently 
cause  extension  of  the  inflammation  to  the  tubes,  and  worse  still,  they  deceive 
the  patient  and  the  physician  with  the  thought  that  something  is  being  done 
towards  a  cure — Avhereas,  little  or  no  real  progress  is  made  against  inflam- 
mation, and  if  malignant  disease  be  present  it  is  allowed  to  deA"elop  till  it  is 
past  cure. 

"In  all  these  cases  in  which  the  trouble  persists  after  a  course  of  treat- 
ment including  a  few  intrauterine  applications,  the  uterus  should  be  carefully 
cleared  out  with  a  curet.  Then  if  the  trouble  is  only  inflammation,  the  patient 
is  in  a. fair  way  to  get  well,  and  if  the  microscopic  examination  of  the  scrap- 
ings shows  malignant  disease,  the  uterus  can  be  removed  in  this  early  stage 
with  a  well-founded  hope  of  saviug  the  patient's  life. 

"  Fibromyomata  are  frequently  multiple,  and  when  only  a  single  tumor 
can  be  felt  it  may  be  of  such  large  size  or  have  existed  so  long  with  but  little 
disturbance,  that  malignancy  is  excluded.  But  there  are  many  cases  in 
which  the  mass  is  small  and  so  far  as  known  has  existed  only  a  short  time. 
In  these  cases  the  most  important  point  in  the  differential  diagnosis  is  the 
change  that  takes  place  in  the  endometrium  in  the  two  diseases. 

"A  fibromyoma  frequently  causes  a  hypertrophic  endometrium  which 
gives  rise  to  discharge  and  hemorrhage. 

"A  malignant  tumor  starting  deep  in  the  uterine  wall  may  at  first  cause 
similar  changes,  but  in  the  course  of  time  and  liefore  it  reaches  a  large  size  or 
passes  beyond  the  limit  of  complete  removal,  it  extends  to  the  endometrium, 
and  characteristic  elements  will  be  found  in  the  uterine  scrapings.  Further- 
more, the  great   majority  of  malignant   growths   of  the  bodv   of  the  uterus 


CARCINOMA    OF    THE    CERVIX    UTERI  771 

tegin  in  the  endometrium  and  so  produce  characteristic  changes  there  in  the 
A^ery  earliest  stage. 

"Therefore,  in  a  case  of  small  tumor  of  doubtful  character,  accompa- 
nied with  discharge  or  bleeding,  curetment  is  advisable  as  a  means  of  diagnosis. 
If  the  uterine  scrapings  do  not  show  malignant  infiltration  we  are  justified  in 
assuming  that  the  tumor  is  a  fibroid,  but  if  the  scrapings  do  show  malignant 
infiltration  the  radical  operation  is.  of  course,  indicated  at  once. 

"Another  point  which  should  be  kept  in  mind  is  that  a  malignant  tumor 
which  at  first  causes  disturbance  of  the  endometrium  by  pressure  or  prox- 
imity only,  may  later  send  its  characteristic  elements  to  the  endometrium 
where  they  can  be  reached  with  the  curet.  Consequently,  Avheii  the  first 
examination  shows  nothing  malignant,  if  signs  of  marked  endometrial  dis- 
turbance again  appear,  the  diseased  tissue  should  again  be  removed  for 
examination. 

"In  the  later  stages  also  of  uterine  tumors,  curetment  is  valuable  as  a" 
diagnostic  means.  For  instance,  a  patient  presents  a  large  tumor  of  the  uterus 
of  doubtful  character,  with  pain  and  discharge  and  marked  disturbance  of 
the  general  health.  Curetment  will  lessen  the  hemorrhage  and  discharge  tem- 
porarily and  will  furnish  tissue  for  examination.  If  the  scrapings  show  no 
malignant  infiltration,  the  tumor  is  probably  a  fibroid  and  removal  may  be 
indicated.  If  the  scrapings  do  show  malignant  trouble,  only  palliative  meas- 
ures are  indicated,  as  the  growth  has  advanced  too  far  for  complete  removal. 

* '  There  remains  still  unmentioned  the  one  form  of  malignant  disease  that 
is  most  difficult  of  positive  diagnosis.  I  refer  to  a  malignant  tumor  growing 
IN  A  FIBROID  or  resulting  from  the  degeneration  of  the  same.  In  a  number  of 
well-authenticated  cases,  malignant  tissue  has  been  found  in  tumors  that  were 
undoubtedly  for  several  years  simple  fibroids.  Fibrocystic  tumors  seem  more 
dangerous  in  this  respect  than  the  solid  tumors.  The  cases  are  not  very  fre- 
quent but  they  do  occur,  and  a  fibroid  that  takes  on  rapid  growth  at  any  time 
near  the  menopause  is  open  to  this  suspicion.  As  the  malignant  infiltration 
is  for  a  long  time  confined  within  the  fibroid,  it  does  not  reach  the  uterine 
canal,  and  a  positive  diagnosis  can  be  made  only  by  removal  of  the  tumor." 

In  the  later  stages  of  carcinoma  the  pressure  symptoms  and  other  com- 
plications mentioned  under  pathology,  develop  and  cause  the  patient  much 
suffering.  Cancerous  cachexia  (a  yellowish  anemic  color  with  emaciation, 
due  to  deterioration  of  the  blood)  appears,  and  also  a  foul  discharge  and 
PERSISTENT  BLEEDING.  If  the  ccrvix  is  iiivolvcd,  a  f ungating  mass  may  be  felt 
in  the  vagina. 

In  the  differential  diagnosis  of  cancer,  the  author  purposely  avoided 
giving  prominence  to  these  symptoms,  for  they  represent  a  late  stage  of  the 
disease.  The  diagnosis  should  be  made  before  such  symptoms  develop,  if  the 
patient  comes  under  observation  in  time. 

In  working  for  general  early  diagnosis  of  cancer  of  the  uterus,  we  meet 


772  MALIGNANT   DISEASE    OF    THE    UTERUS 

with  one  very  serious  difficulty  which,  probably  more  than  any  other,  is 
responsible  for  the  many  deaths  from  this  disease.  It  is  the  want  of  knowledge 
on  the  part  of  the  public  generally,  as  to  the  serious  import  of  irregular 
blood-tinged  vaginal  discharges  in  women  approaching  the  menopause.  A 
very  large  proportion  of  patients  with  cancer  of  the  uterus  do  not  consult  a 
physician  until  the  malignant  infiltration  has  advanced  beyond  cure.  The  dis- 
turbance in  the  early  stage  is  so  slight  (just  a  slight  leucorrhea  streaked  with 
blood  occasionally)  that  the  patient  thinks  it  of  no  particular  significance 
and  neglects  to  have  any  investigation  until  too  late. 

"Whenever  an  occasional  streak  of  blood  or  spot  of  blood  appears  in  a  leu- 
corrheal  discharge,  particularly  in  a  woman  approaching  forty  or  older,  an 
examination  is  urgently  required,  in  order  to  determine  certainly  whether 
or  not  there  is  beginning  cancer  in  the  cervix  or  body  of  the  uterus.  Such 
women  should  seek  medical  advice  at  once,  that  the  cause  of  the  blood  streak 
may  be  determined  without  delay.  Education  of  the  public  in  this  matter  is 
urgently  needed  and  if  carried  on  patiently  and  persistently  and  judiciously, 
will  save  thousands  of  women  from  death  by  uterine  cancer.  However,  as 
has  been  remarked  when  speaking  on  this  subject  some  time  ago,*  "The 
education  of  the  public  in  this  matter  is  an  exceedingly  hard  task.  Of  course 
physicians,  as  individuals,  can  help  by  giving  information  to  their  patients. 
But  there  is  a  larger  medium  of  publicity  that  should  certainly  be  utilized  in 
some  way  in  a  matter  of  such  great  importance  to  the  public.  I  refer  to 
the  public  press  and  periodicals.  This,  however,  is  a  delicate  matter  and  one 
for  concerted  action  only  on  the  part  of  the  profession  as  a  body,  and  not 
for  individual  action.  This  phase  of  the  subject  is  being  already  considered 
in  a  practical  way  and  it  is  hoped  that  at  the  next  meeting  of  the  American 
Medical  Association  the  matter  will  be  thoroughly  discussed  and  some,  definite 
and  effective  steps  taken  for  the  general  dissemination  of  this  much-needed 
information. ' ' 

The  report!  of  the  special  committee  appointed  by  the  American  Medical 
Association  to  consider  this  matter  should  be  read  by  every  physician,  and 
the  information  contained  therein  should  be  disseminated  in  every  prac- 
ticable way. 

That  much  good  can  be  accomplished  by  a  systematic  and  sustained  fight 
in  this  direction  is  shown  by  the  results  in  East  Prussia. 

Winter,  aided  by  the  professional,  sociologic  and  governmental  condi- 
tions there  existing,  carried  on  a  most  successful  campaign  against  this  dis- 
ease. The  report  of  the  first  year's  work  showed,  among  other  things:  (a) 
that  the  proportion  of  carcinoma  patients  who  consulted  a  physician  within 
three  months  after  the  appearance  of  symptoms,  was  raised  from  32  per  cent 
to  57  per  cent;   (b)   that  the  proportion  of  patients  operated  on  within  two 

*The   Promotion   of   Early   Diagnosis   in   Malignant   Disease    of   the   Uterus,   by   H.    S.    Crossen,    M.D. 
Medical  Bulletin  of  Washington  University,   1905. 

tjournal   of  the  American  Medical  Association,   Dec.   8,   1906. 


TREATMENT   OF    CARCINOMA   OF    CERVIX   UTERI  773 

weeks  after  the  first  consultation,  increased  from  78  per  cent  to  90  per  cent; 
and  (c)  that  the  operability  in  patients  seeking  treatment  Avas  raised  from 
62  per  cent  to  74  per  cent. 

Treatment 

For  purposes  of  treatment,  the  cases  of  carcinoma  of  the  cervix  are 
divided  into  two  classes;^ — operable  and  inoperable. 

OPERABLE  CASES 

This  class  comprises,  theoretically,  those  cases  in  which  the  malignant 
disease  is  still  limited  to  tissues  that  admit  of  complete  removal.  Practically, 
it  comprises  those  cases  in  which  there  is  a  chance,  even  a  small  chance,  that 
the  carcinoma  is  lijnited  to  the  tissues  mentioned  and  in  which  the  patient  is 
in  condition,  or  can  be  put  in  condition,  to  stand  the  radical  operation  with 
reasonable  safety.  By  "radical  operation"  is  not  meant  any  particular  form 
of  operation,  but  any  operation  that  removes  all  the  tissues  likely  to  be 
involved  in  that  particular  case. 

As  to  what  tissues  may  be  removed,  by  those  skilled  in  pelvic  work,  that 
is  well  known.  The  removal  of  the  uterus  is  the  least  that  is  to  be  done.  In 
selected  cases,  the  lower  part  of  one  or  both  ureters  may  be  removed,  or  a 
part  or  the  whole  of  the  bladder,  or  a  part  or  the  Avhole  of  the  rectum.  Also, 
the  pelvic  connective  tissue  generally  with  its  contained  lymphatic  vessels 
and  glands,  may  be  cleared  out  to  the  soft  structures  of  the  pelvic  wall, 
and  the  enlarged  lymphatic  glands  about  the  iliac  vessels  may  be  extirpated. 
The  Avriter  does  not  wish  to  be  understood  that  any  of  these  extreme  meas- 
ures should  be  employed  in  any  case,  but  intends  only  to  point  out  what  may 
be  done  and  the  patient  still  survive  in  selected  cases. 

The  question  as  to  the  advisability  of  such  extensive  operative  work  does 
not  turn. upon  any  question  as  to  the  possibility  of  removal  of  these  structures, 
but,  upon  the  probability  that  carcinoma  cells  have  simultaneously  extended 
to  other  and  inaccessible  regions.  Careful  investigations  in  this  direction  have 
been  made  and  many  extensive  operations  have  been  carried  out,  but  the 
question  is  not  yet  settled.  However,  results  so  far  have  not  been  such  as  to 
encourage  operation  in  these  extensive  cases.  ■  '      ' 

The  lesson  to  be  drawn  from  the  work  up  to  the  present  time,  is  'that 
ordinarily,  recurrence  is  practically  certain  when  the  carcinomatous  infiltration 
has  extended  so  that  it  involves  the  bladder  or  the  rectum  or  the  outlaying 
lymphatic  glands  or  the  connective  tissue  around  the  ureters.  When  any  of 
these  structures  are  evidently  involved,  it  is  almost  certain  that  there  are 
scattered  carcinoma  cells  in  adjacent  deeper  and  inaccessible  tissues,  hence 
these  cases  lie  outside  the  operable  class.  There  are  exceptional  cases,  for 
example,  of  distinctly  localized  involvement  in  a  slow-growing  tumor,  where 


774  MALIGNANT    DISEASE    OF    THE    UTERUS 

it  may  be  advisable  to  excise  a  portion  of  the  bladder  or  ureter.  But  for  tlie 
present,  ordinarily,  to  subject  such  a  patient  to  an  attempted  radical  opera- 
tion is  to  cause  her  to  pass  through  the  dangers  and  the  suffering  of  one  of 
the  most  serious  operations  in  surgery,  without  any  reasonable  hope  of  cure. 
If  hysterectomy  as  a  palliative  measure,  is  desired,  that  is  an  entirely  differ- 
ent proposition,  and  is  carried  out  in  a  less  extensive  and  less  dangerous 
v^^ay. 

In  order  to  get  a  clear  understanding  as  to  the  limit  of  the  operable 
class,  it  is  well  to  divide  the  course  of  carcinoma  of  the  cervix  into  three 
stages.  In  the  first  stage  the  disease  is  confined  entirely  to  the  uterus.  Re- 
moval of  the  uterus  will  remove  the  entire  process  and  effect  a  permanent  cure. 
In  the  second  stage  the  carcinoma  cells  have  got  outside  the  uterus  into 
the  parametrium  for  a  short  distance — but  still  not  beyond  the  reach  of  opera- 
tion, provided  the  operation  includes  a  Made  removal  of  the  connective  tissue 
beside  the  uterus.  In  the  third  stage  there  is  evident  involvement  of  the  ureters 
or  of  the  outlying  connective  tissue  or  of  the  bladder  or  of  the  rectum  (with  less 
evident  involvement  of  deeper  and  inaccessible  tissues),  making  complete 
removal  of  all  involved  tissue  impossible. 

The  cases  belonging  to  the  first  and  second  stages  are  operable  as  a 
general  proposition.     The  cases  in  the  third  stage  are  inoperable. 

How  to  Determine  Operability 

How  extensive  is  the  carcinomatous  infiltration — has  it  reached  the  third 
stage?  That  is  the  important  question,  for  the  answer  determines  whether 
or  not  the  patient  is  to  be  subjected  to  radical  operation. 

To  determine  this  absolutely  in  anj^  case  is  impossible.  It  may,  however, 
be  determined  approximately. 

The  signs  upon  which  we  must  depend  largely  for  determining  it  are  the 
induration  (occasioned  by  the  infiltration  of  the  tissues  with  carcinoma  cells 
and  opposing  round  cells)  and  the  fixation  of  the  uterus,  which  is  present 
when  the  infiltration  extends  out  to  the  pelvic  Avail. 

Uterus  Movable,     If  the  uterus  is  freely  movable  operation  is  indicated. 

Uterus  Fixed.  When  the  uterus  is  not  movable,  it  is  then  necessary  to 
determine  whether  the  fixation  of  the  organ  is  due  to  malignant  infiltration 
or  to  inflammatory  infiltration.  If  the  fixation  is  due  to  malignant  infiltration, 
operation  is  not  indicated — the  case  has  already  passed  into  the  third  stage 
and  palliative  measures  only  are  permissible.  If  the  fixation  is  due  to  inflam- 
matory infiltration,  it  is  not  a  bar  to  operation. 

The  infiltration  is  probably  only  inflammatory  if  there  is  a  mass  about 
the  broad  ligament  and  directly  continuous  with  the  carcinomatous  area  of 
the  cervix,  if  it  is  not  tender  and  if  there  is  no  history  of  recent  inflamma- 
tory trouble  and  no  evidence  of  the  same  in  the  pelvis. 


TREATMENT    OF    CARCINOMA    OF    CERVIX    UTERI  775 

The  inflaniniation  is  probably  only  inflammatory  if  there  is  a  mass  about 
one  or  both  tubes  (salpingitis),  if  the  infiltration  of  the  broad  ligament  is 
mostly  in  the  upper  part,  if  the  bladder  and  rectal  walls  are  not  involved  and 
if  the  patient  gives  a  long  history  of  inflammatory  trouble  and  a  short  history 
of  cancer.     In  such  a  case,  radical  operation  is  indicated. 

In  order  to  determine  approximately  the  amount  of  fixation  and  its 
probable  character,  it  is  often  necessary  in  a  doubtful  case  to  employ  exam- 
ination under  anesthesia,  that  deep  palpation  of  all  parts  of  the  pelvis  may  be 
made.  In  such  a  case  a  deep  recto-abdominal  palpation  of  all  the  intrapelvic 
structures,  as  well"  as  the  vagino-abdominal  palpation,  is  usually  advisable. 

This  examination,  upon  which  the  question  of  operation  turns,  is  a  very 
important  procedure  and  requires  much  skill  and  much  experience  Avith  this 
class  of  cases.  If  after  a  thorough  examination,  there  is  reasonable  doubt  as 
to  the  inoperability  of  the  case,  operation  is  indicated,  for  the  patient  is 
entitled  to  every  chance  possible  in  this  otherwise  fatal  disease. 

In  these  doubtful  cases,  the  operation  is  begun  as  an  exploratory  abdom- 
inal section.  After  the  abdomen  is  opened,  the  pelvis  is  thoroughly  explored 
as  to  the  infiltration  and  thickenings  and  their  character,  and  as  to  the 
presence  of  evident  glandular  metastases.  If  this  intraperitoneal  examination 
shows  the  tumor  to  be  an  operable  one,  the  radical  operation  is  carried  out  at 
once.  If  the  tumor  is  found  to  be  inoperable,  the  abdomen  is  closed,  with  or 
without  the  execution  of  one  of  the  palliative  measures  mentioned  later. 

Operative  Measures 

In  the  operable  cases,  what  operation  should  be  chosen"?  In  order  to 
answer  this  question  intelligently,  let  us  see  just  what  the  operation  must 
accomplish.  In  most  of  the  cases  the  disease  has  passed  the  first  stage  before 
the  patient  consults  a  physician.  There  is  already  carcinomatous  infiltration 
of  the  connective  tissue  near  the  uterus — not  sufficient,  perhaps,  to  be  appre- 
ciated by  the  examining  finger,  but  amply  sufficient  to  cause  recurrence.  This 
infiltration  of  the  parametrium  in  practically  all  cases  that  come  to  operation, 
is  the  cause  of  the  lamentable  failure  of  the  old  vaginal  hysterectomy  and  the 
old  abdominal  hysterectomy  as  a  cure  for  cancer  of  the  cervix  uteri.  Occa- 
sionally a  case  was  met  with  in  the  first  stage  (simply  a  small  ulcer  on  the 
vaginal  portion  of  the  cervix  or  a  small  nodule  in  the  interior  of  the  cervix), 
and  in  these  cases  the  ordinary  vaginal  or  abdominal  hysterectomy  removed 
all  the  involved  tissue  and  resulted  in  cure.  However,  the  general  effect 
of  these  occasional  good  results  was  detrimental  rather  than  otherwise,  for 
they  prolonged  the  reliance  on  these  inadequate  operations  for  the  cure  of  the 
disease  and  postponed  the  devising  of  more  effective  operative  measures. 

When  physicians  began,  after  the  lapse  of  some  years,  to  count  up  the 
permanent  cures  from  the  operations  mentioned,  the  results  were  most  dis- 
couraging and  disheartening.    It  was  found  that  five  per  cent  of  cures  was  all 


776  MALIGXAXT   DISEASE    OF    THE   UTERUS 

that  could  be  reasonably  claimed.  Some  operators  who  had  had  many  cases 
could  not  present  one  permanent  cure,  and  a  te^v  lost  all  hope  and  claimed 
that  the  disease  could  not  be  cured  by  operation. 

Careful  investigation  into  the  pathology  of  the  disease  brought  out  the 
cause  of  the  failure  of  the  operative  measures  then  in  vogue,  and  also  pointed 
out  the  way  to  the  methods  which  have  proved  successful  and  are  proving 
more  and  more  successful  as  they  are  used  more  and  more  in  the  early  stage 
of  the  disease. 

The  cause  of  the  failure  of  the  former  methods  was  found  to  be  due  to 
the  extension  of  carcinoma  cells  into  the  parametrium  in  practically  all  cases 
Avhen  the  patient  comes  for  operation.  It  follows  then  logically  and  has  been 
thoroughly  established  by  extensive  experience,  that  any  operation  that  is 
to  be  used  with  a  reasonable  hope  of  success  in  carcinoma  of  cervix,  must 
remove  the  infiltrated  parametrium. 

Any  operation  in  which  the  line  of  excision  lies  close  to  the  uterus,  as  in 
the  old  vaginal  and  abdominal  hysterectomy  for  cancer,  can  not  be  successful 
except  in  certain  rare  cases  where  the  disease  is  just  beginning. 

Jacobs,  in  82  vaginal  hysterectomies,  saw  recurrence  in  every  one.  Some 
series  by  the  old  vaginal  or  abdominal  hysterectomy,  show  a  few  recoveries, 
past  the  five-year  limit — but  they  are  very  few  and  far  between.  McMonigle 
reported  481  hysterectomies  for  cancer  of  the  uterus,  with  479  deaths  from 
recurrence  or  from  the  operation. 

Russel  investigated  the  after  condition  of  48  cases  of  vaginal  hysterectomy 
for  cancer  of  the  cervix,  and  found  that  almost  invariably  there  was  recur- 
rence at  the  site  of  the  scar,  and  not  in  the  region  of  the  lymphatic  glands. 
Another  important  point  in  regard  to  the  operation  is  that  if  traxsplan- 
TATiox  METASTASES  are  to  be  certainly  avoided,  the  infiltration-area  must  not 
be  cut  into  at  any  step  of  the  operation — that  is,  it  is  not  advisable  to  take  out 
the  uterus  and  then  the  infiltrated  tissues  around  the  uterus,  but  the  whole 
infiltrated  area,  including  uterus  and  parametrium,  should  be  removed  as 
one  mass,  the  line  of  excision  being  everywhere  placed  in  healthy  tissue. 
"When  an  incision  is  made  through  infiltrated  tissue,  cancer  cells  are  liable  to 
be  carried  into  healthy  tissue,  where  they  may  grow.  This  has  happened  in 
several  reported  cases.  \Vhere  an  incision  must  be  made  through  infiltrated 
tissue,  it  is  safer  to  make  it  with  the  cautery,  as  that  destroys  all  cells  with 
which  it  comes  in  contact. 

It  must  be  kept  in  mind  also  that  it  is  impossible  to  be  certain  in  any  case 
that  the  parametrium  is  not  invoh'ed,  no  matter  hoAV  early  the  case  nor  hoAv 
perfectly  -normal  the  parametrium  feels.  Sampson  has  demonstrated  con- 
clusively that  in  some  cases  the  carcinoma  sends  out,  by  direct  growth,  very 
fine  prolongations  into  the  parametrium  and,  in  other  cases,  the  carcinoma 
cells  make  short  excursions  into  the  lymph  spaces  of  the  parametrium.  In 
such  cases,  there  is  no  change  in  the  parametrium  appreciable  to  the  exam- 
ining finger. 


TEEATMENT   OF    CARCINOMA   OF    CERVIX   UTERI 


777 


It  is  evident  then  that  any  operation,  whether  vaginal  or  abdominal,  that 
does  not  remove  the  parametrinm,  is  not  admissible  as  an  operation  for  the 
cure  of  carcinoma  of  the  cervix,  except  in  certain  rare  cases. 

Any  operation,  whether  vaginal  or  abdominal,  that  does  remove  the  para- 
metrium, is  admissible  in  that  it  fulfills  one  of  the  essential  requirements. 
"Whether  the  work  is  done  by  way  of  the  vagina  or  by  way  of  the  abdomen,  is 
a  matter  of  secondary  importance.  The  essentials  of  the  operation  are  shown 
in  Fig.  638. 

One  point  to  be  kept  in  mind  is  the  removal  of  the  uterus  and  parame- 
trium intact.  The  broad  ligament,  including  the  tubes  and  ovaries,  should  of 
course  be  removed.     It  is  in  the  lower  part  of  the  broad  ligament,  however. 


Fig.  638.  The  Essentials  for  any  Radical  Operation  for  Cancer  of  the  Cervix  Uteri.  The  excision 
of  structures  as  here  indicated  must  be  carried  out,  whether  the  operation  be  abdominal  or  vaginal.  (Kelly — 
Operative  Gynecology.^ 


that  the  infiltration  extends  the  farthest  and  that  the  principal  operative 
difficulties  are  met  with. 

There  are  various  methods  which  more  or  less  thoroughly  accomplish 
the  removal  of  the  uterus  together  with  all  the  adjacent  and  particularly  the 
parametrean  tissue.  They  are  performed  either  by  the  vaginal  or  the  abdom- 
inal route. 

The  standard  operation  through  the  vagina  is  that  now  generally  known 
as  the  Schauta-Schuckardt  operation,  the  latter  having  suggested  a  unilateral 
or  bilateral  deep  incision  into  the  paravaginal  tissue  which  lays  the  vagina 
wide  open  and  gives  easy  access  to  the  lateral  portions  of  the  parametrium. 

The    abdominal    operation,    though    originally    conceived    and   variously 


778  MALIGNANT    DISEASE    OF    THE    UTERUS 

modified   and    improved   by   other    operators,    is    commonly    designated   the 
IVertheim  operation. 

Each  route  has  its  own  advantages  in  meeting  definite  conditions  in  the 
individual  case.  Everyone  of  these  radical  operations  makes  high  demand 
-upon  the  skill  of  the  operator,  the  vaginal  route  proving  decidedly  less 
dangerous  to  the  patient  than  the  abdominal  route.  On  the  other  hand  the 
latter  method  offers  a  better  opportunity  for  the  removal  of  lymph  glands. 
In  the  hands  of  such  experts  as  Schauta  and  Wertheim  both  operations  have 
.yielded  approximately  identical  results  in  the  percentage  of  absolute  cures 
■obtained  within  five  years  after  the  operations.  Therefore,  the  choice  of  the 
route  will  be  dependent  solely  upon  the  preference  of  the  individual  operator. 
IVithin  the  last  few  years  undeniably  the  abdominal  operations  have  greatly 
^gained  in  favor. 

The  author  prefers  the  abdominal  route  as  a  rule  in  operating  for  cancer 
■of  the  cervix,  but  there  can  be  no  serious  objection  to  the  vaginal  operation 
when  it  includes  the  technic  required  for  the  removal  of  the  parametrium.  It 
-will  hardly  be  necessary  here  to  take  up  the  adva:ntages  and  disadvantages 
■of  the  various  operations  proposed  for  this  disease.  It  probably  will  be  well, 
Iiow^ever,  to  give  an  idea  of  what  removal  of  the  parametrium  means.  A  brief 
■description  of  certain  points  of  any  one  of  the  really  radical  operations  will 
•do  this. 

One  of  the  best  of  the  abdominal  operations  is  that  elaborated  by  Wert- 
Iieim.  The  essential  steps  are  given  in  the  following  quotation  from  the  report 
■of  a  case  upon  which  the  author  operated  in  1903.*  The  patient  was  33  years 
■of  age,  the  mother  of  five  children  and  in  good  general  health.  The  first  symp- 
lom  (some  leucorrhea,  with  prolonged  menstrual  flow)  was  noticed  just  eight 
months  before  the  operation.  Two  months  later  a  blood  streaked  inter- 
menstrual discharge  began.  The  bleeding  increased,  pains  and  weakness 
•«ame  on  and  finally  the  patient,  emaciated  and  weak  from  loss  of  blood, 
■consulted  Dr.  H.  H.  Meyer,  to  see  if  there  was  any  serious  trouble.  He  ex- 
•amined  her,  made  the  diagnosis  and  referred  her  for  operation. 

"Examination  revealed  a  large  bleeding  mass  springing  from  the  cervix 
■and  filling  the  upper  part  of  the  vagina.  The  mass  was  the  size  of  a  small 
:fist  and  so  obstructed  the  upper  part  of  the  vagina  that  it  was  impossible  to 
make  a  satisfactory  examination  of  the  uterus  and  surrounding  tissues.  I 
advised  that  the  patient  submit  to  examination  under  anesthesia,  when  the 
obstructing  mass  could  be  cleared  away  and  the  extent  of  the  parametrial 
involvement  approximately  determined. 

''Under  anesthesia  it  Avas  found,  after  the  projecting  tumor  mass  had 
Tjeen  removed,  that  the  whole  cervix  Avas  involved  and  that  the  growth  ex- 
tended a  short  distance  along  the  anterior  vaginal  wall.    There  was  apparently 


*The   Wertheim   Operation   for   Caiacer   of  the   I.'terus;    Report   of   a    Case,   H.    S.    Crossen,   M.D.,    St. 
IrfOuis  Medical  Review,  June,  1903. 


TREATMENT    OF    CARCINOMA    OF    CERVIX    UTERI  779 

some  infiltration  of  the  parametrium,  particularly  in  the  left  side,  but  still 
the  uterus  Avas  freely  movable. 

''It  was  a  ease  for  radical  operation,  with  a  fair  chance  of  removing  all 
■of  the  involved  tissue. 

"A  few  days  later  I  removed  the  uterus  and  parametrium  by  the  Wert- 
lieim  method.    The  steps  in  the  operation  were  as  follows: 

"1.  After  the  usual  preparation  for  abdominal  section,  including  satura- 
tion of  the  patient  with  tluid  by  giving  her  all  the  water  she  Avould  take  in 
small  quantities  at  short  intervals  for  two  days  before  operation,  the  patient 
was  anesthetized  (ether)  and  placed  in  extreme  Trendelenburg  posture,  the 
body  being  raised  to  an  angle  of  almost  45  degrees. 

"2.  The  abdominal  cavity  was  opened  and  the  incision  enlarged  until  it 
■extended  from  the  umbilicus  to  just  above  the  pubic  joint.  The  fundus  uteri 
was  then  seized  M'ith  a  heavy  traction  forceps  and  the  organ  drawn  strongly 
upward  and  forward. 

"3.  The  left  side  of  the  abdominal  incision  was  then  retracted,  the  small 
intestine  and  the  sigmoid  flexure  were  held  out  of  the  way  and  an  incision 
was  made  in  the  peritoneum  a  trifle  below  the  point  where  the  left  ureter 
■enters  the  true  pelvis. 

"The  ureter  was  easily  found  and  the  incision  in  the  peritoneum  over  it 
was  continued  doAvn  along  the  course  of  the  ureter  to  the  point  Avhere  it 
entered  the  broad  ligament. 

"4.  Then  a  small  silk  ligature  -was  passed  from  this  incision  around  the 
left  ovarian  vessels  and  tied  and  the  ligated  structures  were  cut.  The  round 
ligament  also  was  ligated  and  cut  and  then  the  clear  peritoneum  between  the 
two  ligatures  was  cut  through,  thus  laying  open  the  broad  ligament.  The 
broad  ligament  was  then  opened  well  down  toward  its  lower  part  and  the 
few  bleeding  points  caught  with  forceps. 

"5.  Steps  No.  3  and  No.  4  were  then  carried  out  on  the  right  side. 

''6.  The  peritoneum  at  the  vesico-uterine  junction  was  then  cut  across 
and  the  bladder  was  separated  from  the  uterus. 

"1.  Then  a  finger  was  passed  along  the  right  ureter  from  the  point  Mdiere 
it  entered  the  broad  ligament  forward  until  the  finger  appeared  in  front  of 
the  ligament.  In  this  maneuver  the  little  pocket  or  archway,  in  Avhich  the 
ureter,  lies,  was'  distinctly  felt  and  served  as  a  guide  as  the  finger  was  forced 
forward.  The  finger,  when  through  the  ligament,  had  the  ureter  immediately 
below  and  in  contact  with  it,  while  above  were  the  uterine  vessels  and  the 
parametrium  surrounding  them.  The  opening  was  then  enlarged  outward  and 
the  end  of  a  ligature  carrier  was  placed  on  the  tip  of  the  finger  and  as  the 
finger  was  withdrawn  the  ligature  carrier  was  made  to  follow  it.  The  liga- 
ture was  then  tied  a  little  beyond  the  ureter.  When  this  tissue  was  cut 
through,  the  right  ureter  could  be  seen  all  the  way  from  the  pelvic  brim  to 
its  point  of  entrance  into  the  bladder.     The  parametrial  tissue  lying  to  the 


780  MALIGNANT   DISEASE   OF    THE    UTERUS 

inner  side  of  the  ureter  and  below  it,  was  then  dissected  away,  care  being- 
taken  not  to  free  the  ureter  all  the  way  around,  as  I  wished  to  avoid  any 
interference  with  its  nutrition. 

''The  same  procedure  was  then  carried  out  on  the  left  side.  In  the  left 
side  an  enlarged  lymphatic  gland,  the  size  of  a  bean,  was  found  close  to  the 
uterine  artery  and  somewhat  to  the  outer  side  of  the  ureter.  The  ligature 
was,  of  course,  placed  outside  of  this  gland. 

''8.  The  uterus  and  vagina  were  then  freed  from  the  bladder  and  rec- 
tum and  lateral  tissues  for  about  one-third  of  the  distance  down  the  vagina, 
the  connective  tissue  lying  beside  the  cervix  and  vagina  being  included  in  the 
mass  to  be  removed. 

"9.  An  assistant  then  cleansed  the  vagina,  using  first  cotton-balls  soaked 
in  bichloride  solution  and  then  dry  gauze  repeatedly  until  the  gauze  was  no 
longer  soiled.  Then  a  small  piece  of  gauze  was  placed  against  the  cervix 
and  held  there. 

''10.  From  the  abdominal  cavity  I  then  compressed  the  vagina  with  a 
right-angled  L-forceps,  the  blades  being  applied  just  below  the  gauze  and  well 
below  the  lowest  point  of  malignant  infiltration.  At  the  other  side  of  the 
vagina  another  L-forceps  was  applied  just  below  the  first.  Both  of  these  forceps 
were  clamped  down  hard,  thus  preventing  any  fluid  from  being  squeezed 
past  them. 

"The  vagina  was  then  cut  across  below  the  forceps,  the  stump  of  the 
vagina  being  caught  temporarily  with  three  or  four  artery  forceps.  The  ex- 
cised mass,  with  the  L-forceps  still  attached,  was  removed  from  the  abdomen. 
Catgut  sutures  were  then  applied  about  the  open  end  of  the  vagina  sufficient 
to  stop  the  hemorrhage  and  narrow  the  opening. 

"11.  Search  for  enlarged  glands  was  then  made  on  each  side,  first  about 
the  iliac  vessels  and  then  forward  along  the  pelvic  wall  to  the  obturator  fora- 
men, but  no  enlarged  glands  were  found. 

"12.  After  all  the  bleeding  in  the  pelvis  had  been  checked,  a  narrow  strip 
of  gauze  was  laid  from  each  side  of  the  pelvic  cavity  to  the  opening  vagina, 
the  ends  extending  into  the  vagina.  The  peritoneum  was  closed  over  the 
pelvic  cavity  in  the  usual  way,  all  raw  surfaces  being  turned  down  and  shut 
off  from  contact  with  the  intestines.  The  abdominal  incision  was  then  closed 
with  tier  sutures  of  catgut  and  tension  sutures  of  silkworm-gut. 

"The  operation  was  necessarily  lengthy,  but  the  patient  stood  it  well. 
Convalescence  was  smooth  and  uneventful.  The  highest  temperature  was 
100.8°,  recorded  the  second  day  after  operation. 

"There  was  no  bladder  paralysis,  such  as  is  sometimes  present  after  this 
operation.  The  patient  was  catheterized  for  three  days.  On  the  fourth  day 
she  voided  the  urine  and  continued  to  do  so  afterward  without  disturbance. 

"Beginning  the  fifth  day,  the  gauze  strips  in  the  vagina  and  pelvis  were 


TREATMENT   OF    CARCINOMA   OF    CERVIX   UTERI  781 

pulled  out  a  little  each  day  until  about  the  tenth  day,  when  the  remaining 
portions  were  taken  out  entirely. 

''The  specimen  removed  by  operation  was  submitted  to  Dr.  C.  Fisch  for 
microscopic  examination  for  the  purpose  of  determining,  as  far  as  possible, 
whether  or  not  the  malignant  infiltration  had  extended  beyond  the  line  of 
incision. 

*'Dr.  Fisch  reported  that  the  growth  was  an  epithelioma  and  that  'in  all 
places  examined  the  operative  separation  has  taken  place  in  healthy  tissue.' 

"The  point  at  which  the  cancer  approached  nearest  to  the  margin  of  the 
removed  mass  was  in  the  median  line  anteriorly,  where  the  bladder  was 
separated  from  the  uterus. 

"During  the  operation  the  bladder  separated  from  the  uterus  "without  the 
least  difficulty  and  there  was  no  indication  of  involvement  of  the  bladder  wall. 
The  enlarged  lymph  node  in  the  neighborhood  of  the  left  ureter  showed  no 
cancer  elements,  but  simply  a  marked  hyperplasia.  [The  patient  is  now  (4 
years  after  the  operation)  in  good  health  and  with  no  evidence  of  recurrence.] 

"As  far  as  I  know  this  is  the  first  complete  Wertheim  operation  for  St. 
Louis. 

"In  1900  Wertheim  made  his  first  report  of  this  operation  method.  The 
results  so  far  obtained  have  been  encouraging,  though  not  enough  time  has  as 
yet  elapsed  to  count  the  patients  as  cured.  Last  September,  at  the  Interna- 
tional Gynecologic  Congress  at  Rome,  Wertheim  reported  120  cases  in  which 
he  had  operated  by  this  method.  Of  the  120  patients,  24  died  from  the 
operation.  In  his  first  series  of  thirty  cases,  it  had  been  two  and  a  half  to  four 
years  since  operation.  Of  the  eighteen  of  these  who  survived  operation,  five 
were  not  heard  from,  ten  were  in  good  health  and  in  only  three  was  there  recur- 
rence. 

"The  object  of  this  operation  is  wide  removal  of  the  parametrium,  and 
the  points  in  the  operation  which  seem  particularly  advantageous  are: 

' '  a.  Exposure  of  the  ureter  at  a  point  where  it  is  easily  found,  i.  e.,  at  the 
pelvic  brim. 

"b.  Incision  of  the  peritoneum  from  this  point,  along  the  ureter  to  the 
base  of  the  broad  ligament.  This  brings  nearly  all  the  pelvic  portion  of  the 
ureter  into  view  and  locates  accurately  its  point  of  entrance  into  the  broad 
ligament. 

"c.  Introduction  of  the  finger  through  the  base  of  the  broad  ligament 
close  along  the  ureter.  This  allows  the  ligature  about  the  uterine  vessels  to  be 
placed  well  away  from  the  uterus,  outside  the  ureter,  with  perfect  safety  and 
without  the  delay  incident  to  catheterization  of  the  ureters. 

"d.  The  firm  clamping  of  the  vagina  below  the  growth  by  two  L-forceps, 
one  below  the  other.  This  closes  the  vagina,  which  is  to  be  cut  across,  and 
permits  the  mass  to  be  removed  through  the  abdomen  without  the  possibility 
of  any  contaminating  fluid  being  squeezed  from  the  cervix. 


782 


MALIGNANT   DISEASE    OF    THE    UTERUS 


''e.  All  the  work  is  done  from  the  abdomen,  largely  under  the  eye  and 
without  change  of  posture,  thus  doing  away  with  delay  from  change  of 
posture  and  the  increased  danger  of  sepsis  necessarily  attendant  on  the  'com- 
bined,' or  vagino-abdominal  operations. 


'%. 


Fig.  639.  Specimen  of  comparatively  early  stage  of  cervical  cancer,  spreading  to  vaginal  wall, 
obtained  by  abdominal  radical  operation  after  Wertheim.  Both  uterine  appendages,  the  upper  portion  of 
the  vagina,  and  large  parts  of  the  broad  ligaments  vi'ith  parametrean  tissue  are  removed,  together  with  the 
uterus,  in  this  operation. 


"The  contraindications  to  this  operation  are: 

"1.  Obesity.  When  the  patient  is  very  stout,  the  thick  abdominal  wall 
and  the  pelvic  fat  interfere  with  the  proper  exposure  and  dissection  of  the 
parts. 

"2.  Any  serious  disease  of  the  heart  or  lungs  or  kidneys  or  other  organ 


TREATMENT    OF    CARCINOMA    OF    CERVIX   T'TERI  785 

that  A^-ould  render  the  patient  probably  unable  to  stand  a  long  abdominal 
operation.  In  some  of  such  cases  a  vaginal  hysterectomy,  including,  when 
necessary,  Schuchardt's  incision  beside  the  rectum,  will  give  a  fair  chance 
of  cure  Avithout  unduly  jeopardizing  the  patient's  life.  Much  judgment  as- 
to  choice  of  operation  is  required  in  these  cases.  A  wide  removal  of  tissue,, 
such  as  we  get  in  the  Wertheim  operation,  is  much  to  be  desired.  But  in  a 
poorly  conditioned  patient  this  wide  removal  of  tissue  may  be  purchased  toO' 
dearly.  A  fair  probal^ility  of  complete  removal  and  a  live  patient  is  better 
than  a  greater  probability  of  complete  removal  and  a  dead  patient. 

"3.  Cancerous  infiltration  extending  beyond  the  ureters  or  involving  the 
bladder  or  rectum.  Such  cases  I  do  not  consider  suitable  for  radical  opera- 
tion. Of  course,  I  am  aware  that  some  operators  advise  operation  in  these- 
cases  and  remove  the  infiltrated  portions  of  the  affected  organs  (bladder  or 
rectum).  Sampson,  of  Johns  Hopkins  University,  has  adapted  the  Wertheiin. 
operation  to  these  cases  by  extending  the  dissection  outside  the  ureter  and 
excising  the  involved  portion  of  the  ureter  along  with  the  main  tumor. 

"Such  extensive  operations  are  experimental  as  yet. 

"I  earnestly  hope  some  procedure  may  be  devised  that  will  be  efficient  in: 
these  eases  of  immovable  uterus. 

''But  until  more  hope  can  be  held  out  than  is  justified  by  results  up  to^ 
the  present  time,  I  can  not  advise  such  a  patient  to  submit  to  radical  operation. 

"There  is,  however,  one  class  of  patients  with  uterine  cancer  and  exten- 
sive infiltration,  rendering  the  uterus  immovable,  in  which  I  urge  operation,, 
namely,  those  patients  in  which  there  is  a  probability  or  possibility  that  the 
parametrial  infiltration  is  not  malignant,  but  simply  inflammatory.  The- 
broad  ligament  infiltration  is  more  likely  to  be  simply  inflammatory  if  it  is. 
situated  in  the  upper  part  of  the  ligament,  if  there  is  a  mass  about  one  or  botk 
tubes  (salpingitis)  and  if  there  is  a  long  history  of  inflammatory  trouble  and 
a  short  history  of  cancer. 

"4.  Beginning  cancer  of  the  body  of  the  uterus.  Ordinarily,  in  such, 
cases,  vaginal  hysterectomy  is  preferable,  because  it  is  less  dangerous,  while- 
at  the  same  time  permitting  removal  of  all  tissue  likely  to  be  involved. 

"The  same  may  probably  be  said  of  certain  very  early  cases  of  cancer 
of  the  cervix,  though  that  is  still  a  mooted  point. 

Wertheim  in  his  report  in  1912  had  operated  by  this  method  on  675- 
cases  of  cancer  of  the  cervix.  Of  the  380  patients  operated  more  than  five 
years  ago,  160  were  well  and  free  froin  cancer.  There  was  a  permanent  cure- 
in  43  per  cent  of  all  patients  subjected  to  operation  and  in  53  per  cent  of  the- 
patients  surviving  operation.  The  primary  mortality  of  the  operation  was 
reduced  from  20  per  cent  in  the  first  120  to  9  per  cent  in  the  last  100. 

All  together  during  these  fourteen  years  (1898  to  1912),  1,430  cases  of 
cancer  of  the  cervix  were  examined  in  Wertheim 's  clinic.  Six  hundred  and 
seventy-five  were  operated,  70  refused  operation  and  684  were  inoperable — 


784  MALIGNANT   DISEASE   OF    THE   UTERUS 

giving  50  per  cent  operability.  In  deciding  as  to  operability,  many  points 
must  be  considered — the  extent  of  parametrial  infiltration,  the  fixation  of  the 
bladder  and  rectum,  enlarged  glands  that  may  be  felt,  the  general  condition 
of  the  patient  especially  the  condition  of  the  heart  and  of  the  blood  and  the 
presence  or  absence  of  obesity. 

One  distinct  advantage  of  the  abdominal  operation,  is  the  better  oppor-. 
tunity  it  gives  for  accurate  determination  of  the  extent  of  the  carcinomatous 
involvement  before  beginning  the  operation  proper.  After  the  abdomen  is 
open,  the  pelvis  may  be  thoroughly  explored,  and  the  advisability  of  drting  a 
radical  operation  determined  before  beginning  the  same. 

In  some  cases  that  are  apparently  well  suited  for  radical  operation,  this 
intraperitoneal  examination  shows  that  such  an  operation  would  be  utterly 
useless  and  that  only  palliative  measures  are  permissible.  On  the  other  hand, 
in  apparently  advanced  cases,  this  thorough  exposure  of  the  pelvic  interior 
may  show  that  much  of  the  supposed  extensive  malignant  infiltration  is  only 
an  inflammatory  mass  or  a  fibroid  or  other  non-malignant  growth,  and  that 
radical  operation  is  fully  justified. 

Recurrence  After  Operation.  The  frequency  of  recurrence  has  been  men- 
tioned. The  facts  show  that  the  prognosis  must  in  every  case  be  very  guarded, 
no  matter  how  early  or  how  thorough  the  operation.  A  recurrence  may  be  a 
local  recurrence  (in  or  near  the  scar  of  the  operation)  or  lymph  gland  recur- 
rence (in  some  of  the  lymph  glands  in  the  pelvis  or  lower  abdomen)  or  a 
distant  metastatic  recurrence  (in  some  organ  to  which  cancer  cells  have  been 
carried  by  the  blood  stream).  A  local  recurrence  is  amenable  to  treatment. 
The  preferable  treatment,  usually,  is  thorough  and  wide  excision  with  the 
thermo-cautery.  As  an  additional  precaution,  X-ray  and  radium  treatment 
may  be  used  following  the  excision.  The  diagnosis  of  recurrence  rests  on  the 
same  symptoms  and  signs  as  the  diagnosis  of  the  primary  growth.  Lymph 
gland  metastasis  is  not  amenable  to  cautery  treatment,  but  the  pain  may 
frequently  be  considerably  relieved  by  palliative  measures,  including  X-ray 
and  radium  treatment,  electricity  as  applied  for  the  relief  of  pain,  and  the 
general  and  local  measures  for  diminishing  pelvic  congestion.  The  patient 
should  be  given  morphine  or  other  preparations  of  opium  in  sufficient  quan- 
tities to  prevent  suffering. 

Carcinoma  Complicating"  Pregnancy 

Pregnancy  may  take  place  in  a  woman  with  beginning  carcinoma  of  the 
cervix  or  carcinoma  may  develop  after  impregnation.  In  either  case  the 
effect  of  the  pregnancy  is  to  markedly  hasten  the  growth  of  the  cancer.  Carci- 
noma complicating  pregnancy  is  rare,  being  found  only  three  times  in  a  col- 
lective series  of  54,833  labor  cases.  The  treatment  depends  on  whether  or  not 
the  carcinoma  is  operable. 

Carcinoma  operable.     "When  there  is  a  fair  chance  of  cure  by  radical 


TREATMENT    OF    CARCINOMA   OF    CERVIX   UTERI  785 

operation,  that  should  be  carried  out  at  once,  ''irrespective  of  the  viability 
of  the  fetus." 

Carcinoma  inoperable.  Wlien  the  carcinoma  of  the  cervix  is  inoperable, 
the  life  of  the  child  is  the  thing  of  principal  moment,  and  the  treatment  should 
be  palliative  and  directed  toward  preserving  the  life  of  the  mother  until  the 
child  has  advanced  far  enough  to  have  a  good  chance  of  independent  existence. 
The  details  of  the  treatment  and  the  time  to  interfere  in  an  operative  way 
must  be  determined  by  a  careful  study  of  the  conditions  present  and  the 
probable  developments  in  each  case. 

INOPERABLE  CASES 

In  the  third  stage,  only  palliative  measures  are  permissible.  The  pallia- 
tive measures  are  as  follows: 

1.  Tonics  and  Stimulants.  Give  tonics  and  stimulants  as  indicated,  such 
as  iron,  strychnia,  etc.  Administer  sedatives  in  sufficient  quantity  to  give 
rest — first  the  milder  sedatives  (such  as  bromides  and  phenacetin)  and  later 
morphine.  The  cases  usually  come  to  opium  in  some  form  sooner  or  later 
and,  though  it  should  be  used  only  when  necessary,  it  should  be  used  as  freely 
as  required  to  relieve  the  pain  and  make  the  patient  as  comfortable  as  possi- 
ble in  her  last  months  of  life.  Give  laxatives  as  freely  as  necessarj^  to  prevent 
constipation  from  the  opium.  Regular  and  thorough  bowel  movements  will 
save  the  patient  much  discomfort.  Attention  to  nourishment,  as  in  other 
wasting  diseases  is  of  course  important. 

2.  Ergot  and  other  uterine  astringents  lessen  the  amount  of  blood  in  the 
uterus,  and  in  some  cases  seem  to  diminish  the  swelling  and  pain  and  hemor- 
rhage.   They  are  given  the  same  as  recommended  for  bleeding  in  fibromyoma. 

3.  Douches.  Antiseptic  and  astringent  douches  constitute  an  important 
part  of  the  palliative  treatment.  Hot  bichloride  douches  (1-5000)  wash  away  the 
vaginal  discharge,  diminish  decomposition  in  the  vagina  and  by  the  heat 
diminish  the  pain.  These  may  be  given  one  to  four  times  daily,  depending  on 
the  amount  of  discharge.  If  the  odor  persists  in  spite  of  these  douches, 
lysol  may  be  used  (two  teaspoonfuls  to  the  quart  of  water).  This  is  usually 
very  effective  in  checking  the  odor,  but  must  be  used  sufficiently  often  to 
keep  the  vagina  approximately  clean,  for  the  odor  depends  on  decomposition. 
Weak  formol  (1-5000  to  1-2000)  makes  an  excellent  douche  in  these  cases. 
Begin  Avith  the  weaker  solution  and  advance  to  the  stronger,  if  it  does  not 
cause  smarting. 

If  there  is  a  marked  hemorrhagic  tendency,  the  astringent  douche  of 
alum  and  zinc  sulphate  or  a  tannic  acid  douche  is  indicated. 

4.  Applications.  On  account  of  the  discharge  or  hemorrhage,  strong 
astringent  applications  are  often  needed,  such  as  tannic  acid  and  xeroform 
(half  and  half)  or  liq.  ferri  subsulphatis.  The  uterus  is  exposed  with  the 
speculum  and  the  application  made  to  the  atfected  area. 


786  MALIGNANT   DISEASE    OF    THE   UTERUS 

The  astringent  powders  are  effective  if  held  in  place  by  a  tampon.  Iodo- 
form and  tannic  acid,  equal  parts,  held  in  place  by  a  tampon,  make  a  splen- 
did astringent  dressing  for  this  purpose.  When  the  odor  is  marked,  iodoform 
and  charcoal  are  useful. 

By  means  of  the  tampon  capsules  (see  page  370),  the  desired  powder 
may  be  applied  by  the  patient  at  home  as  often  as  required  after  a  douche. 
She  is  directed  to  till  the  top  of  the  capsule  with  the  powder  before  introduc- 
ing it. 

Formol  (25  per  cent  to  50  per  cent)  applied  as  a  cauterizing  and  harden- 
ing agent  to  the  cancerous  tissue  tends  to  check  the  bleeding  and  foul 
discharge. 

Zinc  chloride  also  is  an  effective  cauterant  in  these  cases  and  has  been 
long  used  for  the  purpose. 

Many  other  cauterant  and  hardening  agents  have  been  used  from  time 
to  time  with  benefit. 

In  the  use  of  all  these  agents  care  must  be  taken  to  prevent  cauteriza- 
tion of  the  vaginal  wall.  Of  course,  these  agents  are  much  more  effective  when 
used  immediately  after  a  thorough  curetting  away  of  the  broken-doAvn  bleed- 
ing tissue.  The  principal  beneficial  effect  is  then  due  to  the  curetment.  But 
when  the  area  is  curetted  under  anesthesia  possibly  the  best  application  to 
make  immediately  afterward,  is  the  actual  cautery,  as  exijlained  below.  The 
other  applications  may  be  used  with  benefit  later. 

5.  Curetment  folloAved  by  cauterization  of  the  affected  area,  constitutes 
one  of  the  most  beneficial  of  the  palliative  measures.  In  some  exceptional 
cases  this  may  be  carried  out  satisfactorily  without  an  anesthetic. 

Under  anesthesia,  however,  the  curetment  may  be  made  much  more 
thorough,  and  ragged  portions  of  cervix  and  vagina  may  be  clipped  off.  The 
cauterization  also  with  the  Paquelin  or  electric-cautery,  is  made  much  more 
thorough — the  walls  of  the  cavity  being  thoroughly  charred  for  quite  a  dis- 
tance below  the  surface,  care  being  exercised,  of  course,  not  to  cause  deep 
sloughing  toward  the  bladder  or  rectum,  if  adherent.  After  the  baking  of 
the  surfaces,  the  cavity  is  packed  with  the  iodoform  gauze,  and  the  vagina  is 
packed  with  the  same.  The  effect  of  the  curetment  and  cauterization  under 
anesthesia  is  much  more  marked  than  without  anesthesia.  In  doubtful  cases, 
Avhere  an  examination  under  anesthesia  is  to  be  made  to  determine  the 
advisability  of  a  radical  operation,  it  is  well  to  have  the  things  ready  so  that 
if  the  carcinoma  is  found  to  be  an  inoperable  one,  palliative  curetment  may 
be  at  once  carried  out. 

The  improvement  from  a  thorough  curetment  and  cauterization  is  usually 
marked.  The  constant  discharge  and  loss  of  blood  is  checked  temporarily 
and  the  patient  picks  up  considerably,  sometimes  becoming  well  enough  to 
take  up  work  formerly  dropped.  Eepeated  cauterization,  as  indicated  by  the 
recurrence  of  bleeding  or  foul  discharge,  is  very  beneficial.    In  some  cases  the 


TREATMENT  OF  CARCINOMA  OF  CERVIX  UTERI  *      787 

extensive  scar-tissue  formation  from  repeated  cauterization  exercises  a  re- 
markable inhibitory  effect  on  the  cancer — checking  its  growth  and,  in  rare 
cases,  even  causing  retrogression.  At  the  St.  Louis  meeting  of  the  American 
Medical  Association  (June,  1910),  a  number  of  cases  were  reported  in  which  this 
apparent  retrogression  was  so  marked  that  the  supposed  inoperable  carci- 
noma of  the  cervix  became,  after  repeated  cauterization,  operable  and  Avas 
then  removed  by  radical  operation,  with  permanent  cure.  While  such  a 
result  is  very  exceptional,  yet  the  possibility  of  its  occurrence  must  be  kept 
in  mind  and  should  encourage  careful  and  persistent  treatment. 

6.  Curetment  Followed  by  Acetone  Applications  has  given  excellent  re- 
sults. It  was  proposed  by  Gellhorn.  It  has  the  distinct  advantage  that,  in 
suitable  cases,  the  foul  odor  and  the  bleeding  may  be  kept  away  without  the 
repeated  anesthesia  necessary  where  dependence  is  placed  on  curetment  and 
cauterization  at  intervals.  It  is  applied  as  follows:  AVith  a  sharp  curet  all 
the  broken  do^vn  tissue  is  cleared  out,  leaving  a  cavity  with  firm  walls.  This 
thorough  curetment  is  best  made  under  general  anesthesia.  The  cavity  is 
sponged  clear  of  blood  and  debris,  and  then  quickly  packed  with  gauze  wrung 
out  of  very  hot  water.  This  tends  to  check  the  oozing  and  is  to  be  held  firmly 
in  place  while  the  patient's  hips  are  elevated  to  the  Trendelenburg  posture 
in  preparation  for  the  acetone  application.  Then  the  vulva  and  vaginal  walls 
are  coated  with  vaseline,  the  hot  packing  is  removed  and  a  tubular  speculum 
large  enough  to  surround  the  greater  part  of  the  raw  cavity  is  introduced  and 
pressed  firmly  against  the  cervix.  The  pure  acetone  is  then  poured  into  the 
speculum  (through  a  funnel  or  simply  from  the  bottle)  in  sufficient  cjuantity 
to  fill  the  end  of  the  speculum  for  an  inch  or  so.  Keep  the  acetone  thus  in 
contact  with  the  raw  surface  for  thirty  minutes.  Then  the  acetone  is  removed 
by  soaking  it  up  with  cotton  in  forceps  or  by  lowering  the  table  and  allowing 
it  to  run  out  of  the  speculum.  After  the  cavitj'  is  dried  with  cotton,  a  tampon 
is  introduced  through  the  speculum  and  held  in  place  as  the  speculum  is  with- 
drawn. This  tampon  may  be  left  in  place  for  several  hours,  to  absorb  any 
acetone  left  and  thus  prevent  irritation  of  the  vaginal  wall.  The  coating  of 
the  vulvar  and  vaginal  surfaces  with  vaseline  is  to  prevent  irritation  by 
stray  drops  of  the  acetone.  The  acetone  application,  without  curetment,  is 
to  be  repeated  twice  weekly  until  the  cavity  is  Avell  contracted,  and  after  that 
occasionally  as  needed  to  prevent  bleeding  and  odor.  The  application  may 
last  30  to  45  minutes — the  longer  the  better  as  a  rule.  The  speculum  is  to  be 
held  in  place  all  this  time.  Usually  the  patient  can  steady  the  speculum  in 
place  after  having  been  shown  how  to  do  so. 

7.  Partial  or  Complete  Vaginal  Hysterectomy  as  a  palliative  measure  is  of 
service  in  suitable  cases.  By  this  means  a  large  part  of  the  cancerous  mass  is 
removed,  the  discharge  and  hemorrhage  are  checked,  pressure  in  the  pelvis  is 
relieved  and  the  patient  is  made  more  comfortable  for  several  months  and 
sometimes  longer. 


788  MALIGNANT   DISEASE    OP    THE   UTERUS 

Partial  extirpation  by  the  cautery,  after  the  method  of  Byrne,  is  the  pref- 
erable plan  usually.  A  large  part  of  the  cervix,  with  as  much  of  the  body  as 
seems  advisable,  is  extirpated  by  the  cautery  and  the  remaining  surfaces  are 
thoroughly  baked.  The  effect  of  the  heat  seems  to  have  some  influence  ex- 
tending a  considerable  distance  beyond  the  cauterized  tissues,  as  indicated  by 
the  long  freedom  from  recurrence  on  the  cauterized  surface,  though  the  deeper 
portions  of  the  infiltration  may  continue  to  grow.  When  applied  thoroughly 
in  a  way  to  secure  satisfactory  results,  amputation  is  almost  as  formidable 
an  operation  as  vaginal  hysterectomy  and  should  be  used  only  when  every- 
thing is  at  hand  to  meet  the  dangers  and  difficulties  that  may  arise. 

8.  Ligation  of  the  Ovarian  Arteries  and  other  easily  accessible  arteries 
supplying  the  region  of  the  tumor,  together  with  the  removal  of  the  adnexa, 
may  be  made  use  of  in  some  cases.  For  example,  where  there  has  been  an 
exploratory  abdominal  section  and  the  carcinoma  is  found  inoperable,  the  ves- 
sels mentioned  may  be  ligated  to  diminish  the  blood  supply  and  retard  the 
growth.  The  effect  as  a  rule  is  not  very  marked.  Kosler  reports  several 
cases  treated  by  ligation.  There  was  some  temporary  improvement,  but  the 
hemorrhage  returned  in  a  short  time. 

9.  X-Ray  and  Radium  Treatment.  X-ray  treatment  relieves  the  pain  and 
bleeding  in  some  cases,  but  the  high  claims  as  to  curative  results  in  cases  of 
carcinoma  of  the  cervix  have  not  been  sustained.  It  may  be  used  as  a  pallia- 
tive measure  in  inoperable  cases,  but  even  then  it  is  not  likely  to  produce  as 
good  results  as  a  partial  excision  of  the  uterus  by  cautery  or  even  as  a  thor- 
ough curetment  and  cauterization  of  the  cavity. 

Radium  treatment  is  still  in  its  experimental  state.  A  clear  conception 
of  the  present  status  of  the  question  can  be  gained  from  quotations  taken 
from  articles  of  recognized  authorities,  published  in  1915. 

J.  G.  Clark  feels  that  no  extreme  degree  of  optimism  can  be  gathered  from 
the  reports  of  the  various  large  clinics,  since  they  all  point  to  the  one  fact 
confirmed  by  his  own  experience,  that  the  deeper  metastases  are  not  reached 
by  the  radium  rays,  and  that,  therefore,  as  in  the  results  of  the  operation  the 
ultimate  fate  of  the  patient  chiefly  depends  upon  early  diagnosis.  There  is 
not  sufficient  evidence  in  favor  of  radium  to  justify  one  in  using  it  as  a  sub- 
stitute for  surgical  measures  in  operable  cases.  Its  use  is  unquestionably  ad- 
visable both  before  and  after  operation.  In  inoperable  cases  it  presents  the 
best  method  of  therapy  available  at  the  present  day.  Apparent  cures  have 
been  observed  in  some  markedly  advanced  cases,  and  in  those  patients  who 
are  not  ultimately  cured,  there  is,  as  a  rule,  a  decided  amelioration  of  all 
symptoms.  In  many  instances  offensive  discharges  and  hemorrhages  disap- 
pear promptly.  Occasionally  neighboring  tissues  are  injured  by  the  rays, 
leading  to  necrosis  and  formation  of  fistulae,  accidents  which  can  be  pre- 
vented successfully  by  correct  technic. 

.1    .  Kelly  and  Burnam  (Jour.  Amer,  Med.  Assn.,  1915)  report  a  series  of  213 
cases  of  cervical  carcinoma  treated  by  radium.     Of  these,  14  were  operable 


CARCINOMA   OF    THE    CORPUS   UTERI  789 

and  199  inoperable  or  inoperable  recurrent  cases.  Most  interesting  are  the 
results  obtained  in  the  latter  group.  Fifty-three  of  them  have  been  clinically 
cured,  109  markedly  improved,  and  in  35,  conditions  remained  uninfluenced. 
While  in  most  of  these  cases  the  time  elapsed  is  too  short  to  pronounce  them 
definitely  ''cured,"  the  complete  disappearance  of  all  visible  and  palpable 
symptoms  even  in  far  advanced  cases  at  least  is  extremely  encouraging. 
But  even  in  the  non-cured  patient  the  general  improvement  is  so  marked,  that 
Kelly  and  Burnam  emphasize  that  this  benefit  alone  makes  radium  one  of  the 
greatest  additions  to  existing  methods  of  treatment  of  cancer. 

Flatau  is  thoroughly  in  accord  with  the  marked  change  that  has  occurred 
in  all  the  larger  German  clinics.  Many  of  the  leading  German  gynecologists 
are  now  advocating  radium  therapy  in  all  cases  of  uterine  cancer,  whether 
seen  early  or  late.  In  many  of  these  clinics  the  radical  operation  now  is  per- 
formed only  rarely. 

10.  Interstitial  Injections.  Injections  of  various  substances  into  the  can- 
cerous mass  to  cause  sloughing  is  sometimes  used  with  benefit.  It  is  an  un- 
certain method,  however,  and  it  is  very  questionable  if  as  much  can  be  ac- 
complished as  by  a  thorough  curetment  and  cauterization.  The  same  may  be 
said  of  various  substances  used  for  the  dissolving  of  fungous  cancerous  tissue. 

11.  Toxins.  Much  work  has  been  done  with  the  idea  of  developing  a 
toxin  or  antitoxin  or  serum  that  would  check  the  growth  of  malignant  tumors, 
but  so  far  nothing  satisfactory  has  been  created.  Coley's  toxin  (made  from 
a  culture  of  the  streptococcus  and  the  bacillus  prodigiosus)  has  produced  oc- 
casional beneficial  effects,  principally  in  sarcoma.  But  the  results  in  car- 
cinoma have  not  been  such  as  make  its  use  worth  while.  Doyen's  cancer 
serum  proved  a  failure.  It  is  to  be  hoped  that  the  present  wave  of  investiga- 
tion into  the  causes  of  malignant  disease  will  produce  something  of  real  value. 

CARCINOMA  OF  THE  CORPUS  UTERI 

Adeno-carcinoma  is  the  variety  usually  found  here.  It  begins  in  the 
endometrium,  consequently  the  tumor  tissue  is  accessible  to  the  curet  at  a 
very  early  stage.  The  growth  is  for  a  long  time  confined  to  the  tissues  imme- 
diately about  the  uterine  cavity,  the  extension  to  the  periuterine  tissue  being 
slow  usually  in  carcinoma  of  the  corpus  uteri — hence  the  chance  of  cure  is 
much  better  (Fig.  645).  Cancers  of  the  corpus  uteri  constitute  a  distinct 
class,  having  a  better  prognosis  than  cancer  of  the  cervix  uteri,  and  requiring 
as  a  rule  less  extensive  operative  treatment.  A  carcinoma  of  the  corpus  uteri, 
still  in  an  early  stage,  is  shown  in  Figs.  640,  641,  and  one  far  advanced  is 
shown  in  Figs.  642,  646. 

Chorioepithelioma  is  a  peculiar  form  of  carcinoma  arising  from  the  fetal 
cells  covering  the  chorionic  villi  (Figs.  648,  649,  650).  A  striking  feature  is  the 
early  penetration  of  blood  vessels,  with  resulting  metastases  to  distant  or- 
gans, which  makes  it  an  exceedingly  fatal  gro^vth,  even  when  removed  com- 


790 


MALIGXAXT    DISEASE    OF    THE    UTERUS 


Fig.  640.  Beginning  Carcinoma  of  tiie  C  irpus  Uteri.  There  is  no  external  sign  of  tlie  growth  at 
this  stage,  except  an  occasional  streak  of  blood  in  the  leucorrheal  discharge.  The  diagnosis  must  be  made 
by  curetment.     (Cullen — Cancer  of  the  Uterus.) 


Fig.   541.     A  corpus  carcinoma  apparently  limited  to  Fig.   642.     Coipus     carcinoma     farther    advanced, 

the  mucosa  lining  of  the  uterine  cavity.  invading    the   muscular    layer   but    leaving    peritoneal 

cover   of   uterus  still   intact. 


CARCIXOMA    OF    THE    CORPUS    UTERI 


791 


paratively  early.  Care  should  be  taken  to  exclude  it  whenever  there  is  per- 
sistent bleeding  coming  on  some  weeks  or  months  after  confinement  or  mis- 
carriage.   It  is  especially  liable  to  occur  following  hydatidiform  mole.     Such 


0W   ' 

^-m^m^ 

''f^^^^^^^H 

■" 

-  -^-_ 

■m. 

iSfiSjJ^^H^ 

Fig.  643.  Adenocarcinoma  of  the  corpus  uteri.  This  is  a  section  of  the  entire  thickness  of  the 
wall  of  the  uterus.  The  endometrium  (left  end)  has  been  largely  removed  by  a  diagnostic  curettage  (Fig. 
109)   a  few  days  before  the  hysterectomy. 


Fig.  644.  Same  growth  as  in  Fig.  643,  higher 
power.  This  is  in  a  portion  of  the  growth  where 
the  adenomatous  formation  is  well  marked. 


Fig.  645.  Same  growth  as  in  Fig.  643,  higher 
power.  This  is  at  the  spreading  edge  of  the  growth 
and  shows  the  carcinoma  penetrating  the  muscle 
tissue. 


was  the  history  of  the  specimen  shoAvn  in  Fig.  647.  This  patient  was  first 
seen  some  months  after  the  expulsion  of  a  large  hydatidiform  mole.  The 
immediate  cause  of  the  consultation  was  repeated  uterine  hemorrhage,  dif- 
ficult to  control.    Curettage  gave  tissue  that  showed  malignant  disease  of  the 


792 


MALIGNANT   DISEASE    OF    THE    UTERUS 


corpus  uteri.    A  hysterectomy  was  done,  and  sectioning  of  the  removed  uterus 
showed  a  typical  chorioepithelioma. 

Malignant  Adenoma  and  Endothelioma  are  rare  forms  of  malignant  dis- 
ease, which  do  not  require  special  description  here. 

Symptoms,  Diagnosis,  Treatment 

The  symptoms  and  diagnosis  are  much  the  same  as  for  carcinoma  of  the 
cervix,  and  are  presented  in  detail  on  pages  766  to  773.  In  the  early  stage  a 
positive  diagnosis  can  be  made  only  by  curettage  and  microscopic  examina- 


^i 


3'  ;^. 


Fig.  646. 


^. 


Adenocarcinoma  of  the  Corpus  Uteri  in  an  advanced  stage.     (Cullen — Cancer  of  the  Uterus.) 


tion  of  the  curettings.  Chronic  endometritis,  particularly  that  associated  with 
senile  changes,  is  the  affection  with  which  it  is  most  likely  to  be  confounded. 
A  very  practical  question  is,  "In  what  cases  is  it  advisable  to  do  curettage 
in  order  to  exclude  malignant  disease  of  corpus  uteri?"  In  all  cases  in  which 
the  bloody  uterine  discharge  persists  in  spite  of  treatment  for  endometritis. 
When  a  patient,  near  the  menopause,  comes  complaining  of  irregular  men- 
struation or  irregular  bloody  discharge,  and  examination  shows  no  trouble 
Avith  the  cervix,  no  uterine  fibroid  and  no  periuterine  disease,  it  is  best  to  as- 
sume that  the  bleeding  is  due  either  to  chronic  endometritis  or  to  beginning 


CARCINOMA   OF    THE    CORPUS    UTERI 


793 


malignant  disease  of  the  endometrium.  If  the  cervix  is  somewhat  open,  try, 
in  the  office  examination,  to  secure  some  tissue  from  within  the  uterus.  If 
this  is  not  practical  and  the  probabilities  are  in  favor  of  endometritis,  put 
the  patient  on  the  ergotin  capsule  and  watch  for  two  or  three  weeks.  If  the 
bloody  discharge  ceases,  that  points  to  endometritis  and  the  treatment  is  con- 
tinued. If  the  bloody  discharge  persists  or  if  it  returns  after  cessation,  then 
insist  on  curettage.  In  such  a  case,  if  tissue  showing  positive  evidence  of 
malignancy  can  be  secured  in  the  office  examination,  it  obviates  double 
anesthesia.     On  the  other  hand,  malignant  disease  ordinarily  can  not  be  ex- 


Fig.  647.  A  Chorioepithelioma  of  the  Uterus.  The  uterus,  which  is  about  one-half  larger  than  normal, 
has  been  opened  from  the  posterior  surface  and  spread  out.  Projecting  from  the  endometrial  surface  on  the 
right  side  near  the  fundus  is  a  nodule  which  has  been  incised.  It  is  the  size  of  a  walnut  and  extends  into  the 
wall  almost  to  the  peritoneum.  Sections  from  this  nodule  show  the  characteristic  structure  of  chorioepi- 
thelioma. The  fact  that  in  chorioepithelioma  there  is  early  erosion  of  the  blood  vessels  and  early  metastasis 
to  distant  organs  should  in  no  wise  discourage  operation  in  this  class  of  tumors,  but  should  simply  stimulate 
us  to  greater  endeavor  to  make  the  diagnosis  at  the  earliest  possible  moment.  This  patient  was  heard  from 
more  than  five  years  after  the  operation,  and  was  still  well  and  with  no  evidence  of  recurrence. 


eluded  except  by  a  thorough  curettage  under  anesthesia,  which  means  sys- 
tematic removal  of  endometrial  tissue  from  all  parts  of  the  uterine  cavity. 
Another  important  point  is  that  all  the  curettings  must  be  preserved  and  sub- 
jected to  the  microscopic  examination.  For  points  in  regard  to  collecting 
and  transmitting  curettings  see  page  134. 

The  treatment  for  carcinoma  of  the  corpus  uteri  is  complete  hysterectomy 
at  once.  When  the  disease  is  discovered  early,  ordinary  hysterectomy,  either 
abdominal  or  vaginal,  will  practically  always  suffice  to  remove  all  involved 
tissue.  In  the  advanced  eases  removal  of  more  or  less  of  the  parametrium  and 
other  periuterine  tissues  is  required. 


794 


MALIGXAXT    DISEASE    OF    THE    UTERUS 


SARCOMA  OF  THE  UTERUS 

-  A  sarcoma  is  a  malignant  growth  arising  from  connective  tissue  or  con- 
nective tissue  derivatives.  The  cause  of  sarcoma,  like  that  of  carcinoma,  is 
not  knovii.  About  the  same  theories  have  been  brought  forivarcl  to  account 
for  it.  Sarcoma  diifers  from  carcinoma  in  that  it  may  occur  at  any  age 
(though  more  frequent  from  the  age  of  40  to  60),  and  furthermore  it  is  not 
especially  associated  with  child-bearing. 

Sarcoma  may  appear  as  a  general  infiltration  of  the  endometrium  or  as  a 


Fig.   648.     Chorioepithelioma  of  uterus  with  distinct  metastatic   growths  in  uterine  wall   and  cervix. 


distinct  tumor  (Figs.  651,  654,  657).  By  edematous  change,  grape-like  masses 
may  form,  either  in  sarcoma  of  the  cervix  (Fig.  292)  or  in  sarcoma  of  the  body 
of  uterus.  The  sarcomata  beginning  in  the  endometrium  are  generally  of  the 
round-cell  variety  (Figs.  655,  656).  Sarcomata  of  the  muscular  part  of  the 
uterine  wall  u.sually  come  from  sarcomatous  degeneration  of  fibromyomata 
(Figs.  618  and  619). 

The  sarcomata  grow  rapidly  or  sloMdy,  depending  on  the  character  of 


SARCOMA    OF    THE    UTERUS 


795 


the  particular  tumor.     They  infiltrate  adjacent  tissues  like  the  carcinomata 
and  cause  death  in  about  the  same  time. 

The  symptoms,   diagnosis  and  treatment  of  sarcoma  of  the  uterus  are 


Fig.   649.      Section     of     chorioepithelioma     shown 
in   Fig.   648. 


Fig.  651.  Beginning  Sarcoma  of  tlie  Corpus  Uteri. 
At  this  Stage  there  is  no  external  evidence,  except 
blood  streaks  in  the  discharge.  The  diagnosis  must  be 
made   by   curetment.      (Kelly — Operatize    Gynecology.) 


■^^ 


'*    . 


«• 


'^*i 


i*-  ^ 


H        "T 


't       % 


« 


4^ 


<!«>.. 


5.  r 


Fig.  650.      Same  section  as  shown  in  Fig.  649,  under  higher  power.. 


796 


MALIGNANT   DISEASE   OF    THE    UTERUS 


practically  the  same  as  for  carcinoma.  A  beginning  sarcoma  is  shown  in  Fig. 
651,  and  one  more  advanced  in  Fig.  653.  It  sometimes  occurs  in  children.  Oc- 
casionally it  appears  in  the  form  of  a  grape-like  mass  attached  to  the  cervix, 
as  shown  in  Fig.  292.  A  pediculated  sarcoma  projecting  into  the  vagina  is 
sho-v\m  in  Figs.  291  and  654.  A  sarcoma  originating  in  a  fibroid  is  shown  in 
Figs.  618,  620,  621. 


Fig.  652.     Slight  Enlargement  of  the  Uterus  caused  by  Sarcoma.     (Cullen — Cancer  of  the  Uterus.) 


Fig.  653.     Advanced   Sarcoma  of  the  Corpus  Uteri.      (Kelly — Operative   Gynecology.) 


sarco:ma  of  the  utercs 


797 


Fig.  654.  Sarcoma  of  endometrium  protruding  from  the  cervix  in  form  of  a  polypus.  In  this  case 
several  attempts  had  been  made  preceding  radical  operation  to  remove  this  polypus,  the  true  condition  (see 
Fig.    657)    not   having  been   recognized. 


m 


Fig.  655.  Photomicrograph  of  section  from  speci- 
men shown  in  Figs.  654  and  657.  The  picture  shows 
the  sharp  line  of  demarcation  between  the  sarcom- 
atous tissue  and  the  fairlv  normal  uterine  wall. 


t<3^^ 


V       V'n*^ 


Fig.  656.  Portion  of  Sarcomatous  Endometrium 
(Fig.  655)  in  immediate  contact  with  underlying 
myometrium.      High   power. ' 


798 


MALIGNANT    DISEASE    OF    THE    UTERUS 


Fig.    657.      Sarcoma   of   the    Endometrium.      Entire   utei  u;    after    extirpation    (same    as    Fig.    65-!),    laid    open. 


CHAPTER  X 

PELVIC  INFLAMMATION 

Pelvic  inflammation  is  the  term  applied  to  inflammation  in  the  pelvis 
outside  the  uterus.  The  inflammatory  process  may  be  located  in  the  Fallopian 
tubes,  in  which  case  it  is  called  "salpingitis,"  or  it  may  be  in  the  ovary,  in 
which  case  it  is  called  "oophoritis,"  or  in  tlie  peritoneum,  where  it  is  known 
as  "pelvic  peritonitis,"  or  it  may  be  in  the  connectiA'e  tissue,  where  it  con- 
stitutes "pelvic  cellulitis."  The  cause  of  these  various  forms  of  inflammation 
is  the  same — viz.,  infection — the  symptoms  are  much  the  same,  the  treatment 
is  in  many  respects  the  same,  and  two  or  three  of  the  lesions  are  usually  asso- 
ciated— in  some  cases  so  intimately  associated  that  it  is  difficult  to  determine 
which  is  the  most  important.  Consequently,  from  a  practical  standpoint,  it  is 
best  to  consider  all  these  lesions  together  under  the  one  comprehensive  term 
"  pelvic  inflammation. ' ' 

Before  taking  up  the  disease  proper,  attention  must  be  called  to  some 
points  in  the  anatomy  of  the  structures  involved. 

POINTS  IN  ANATOMY 

Of  Fallopian   Tubes,  Pelvic   Peritoneum,   Pelvic   Connective   Tissue. 

FALLOPIAN  TUBES 

The  Fallopian  tubes,  or  oviducts,  are  two  small  muscular  tubes,  one  on 
either  side,  which  extend  from  the  fundus  uteri  outward  in  the  upper  part 
of  the  broad  ligament  toward  the  pelvic  wall  (Figs.  4,  5).  Each  tube  has  a 
small  central  cavity  extending  its  whole  length  (Fig.  505).  The  inner  end 
of  this  cavity  communicates  with  the  uterine  cavity  and  the  outer  end  opens 
into  the  peritoneal  cavity.  Thus  there  is  a  direct  opening  from  the  outside 
of  the  body  into  the  great  peritoneal  sac,  through  the  vagina,  uterus  and  Fal- 
lopian tubes  (Fig.  658).  This  is  why  infection  of  the  genital  tract  in  a  woman 
leads  to  peritonitis  so  much  more  frequently  than  infection  of  the  genital 
tract  in  a  man— the  infection  in  the  vagina  simply  extending  along  this  mucous, 
tract  directly  into  the  peritoneal  cavity. 

The  tubes  vary  considerably  in  size  and  somewhat  in  shape  in  different 
individuals.  The  length  of  each  tube  is  three  to  five  inches  and  the  direction 
is  outward,  backward,  downward  and  inward — somewhat  resembling  a  shep- 
herd's crook  and  partly  surrounding  the  ovary  (Fig.  4). 

799 


800 


PELVIC    INFLAM^IATION 


That  portion  of  the  tulDe  lying  in  the  uterine  wall  is  known  as  the  inter- 
stitial portion  or  uterine  portion.  It  has  a  very  narrow  Inmen  (Fig.  505). 
That  portion  of  the  tube  extending  from  the  margin  of  the  uterus  to  the  be- 
ginning of  the  curve  is  called  isthmus.  It  is  about  the  diameter  of  a  slate 
pencil  and  is  firm.     The  lumen  is  small,  but  becomes  gradually  larger  toward 


Fig.  658.  A  Diagrammatic  Section  of  the  Genital  Canal.  Notice  the  continuous  opening  from  the 
vulva  through  the  vagina,  uterus  and  Fallopian  tubes  to  the  peritoneal  cavity.  This  is  the  reason  genital 
infection  extends  to  the  peritoneal  cavity  so  much  more  frequently  in  women  than  in  men.  (Waldeyer — 
Das  Becken.)  _ 


the  outer  end.  The  outer  curved  dilated  portion  of  the  tube  is  known  as  the 
ampulla.  It  is  about  the  size  of  a  lead  pencil  and  the  lumen  also  is  much 
larger  than  that  of  the  isthmus  (Fig.  505).  The  outer  end  of  the  tube  is 
kno"\vn  as  the  fimbriated  extremity  or  the  infundibulum.  This  consists  of  a 
funnel-shaped  expansion  surrounded  by  a  fringe  of  slender,  finger-like  proc- 


POINTS    IN    ANATOMY  801 

esses  called  ''fimbriae."  One  of  these  extends  to  the  ovary  and  is  attached 
there  and  is  called  the  "ovarian  fimbria." 

In  structure  the  wall  of  the  tube  is  largely  muscular,  resembling  the 
uterus.  In  fact  it  is  derived  from  the  same  fetal  organ  as  the  uterus  (Fig. 
781).  The  tube  lies  beneath  the  peritoneum  of  the  upper  margin  of  the  broad 
ligament  and  its  wall  presents  three  layers — peritoneal,  muscular  and  mucous. 

The  peritoneal  layer  does  not  differ  materially  from  peritoneum  else- 
where. It  is  composed  of  flat  endothelial  cells  lying  on  a  basis  of  firm  con- 
nective tissue.  Immediately  beneath  the  peritoneum  is  a  layer  of  connective 
tissue  sometimes  called  the  subperitoneal  layer.  In  this  run  blood  vessels 
and  lymphatics.  The  interstitial  portion  of  the  tube  has,  of  course,  no  peri- 
toneal layer,  as  the  muscular  tissue  of  the  tube  is  in  immediate  contact  with 
the  muscular  tissue  of  the  wall  of  the  uterus. 

The  muscular  layer  of  the  tube  is  composed  of  involuntary  muscular  tis- 


r 


Fig.  659.  Fig.   660. 

Fig.  661. 

Fig.   659.     The  mucous  layer  of  the  tube  is  placed  directly  on  the  muscular  layer. 
Fig.   660.      Same  as  Fig.  659,  under  higher  power. 

Fig.   661.     The  mucosa   is   much   folded  longitudinally.      The   depressions,    looking   like   glands,    in   the 
■cross  section,   are   due  simply  to  the  folds   of  the   mucous  membrane. 

sue,  disposed  in  two  strata,  an  outer  longitudinal  and  an  inner  circular.  Both 
these  strata  are  continuous,  with  similar  muscular  strata  in  the  uterus.  The 
internal  stratum  sends  prolongations  of  muscular  tissue  into  the  four  prin- 
cipal folds  of  the  mucosa.  The  muscular  layer  is  thinner  at  the  abdominal 
end  than  at  the  uterine  portion  of  the  tube.  The  increased  thickness  of  the 
wall  at  the  abdominal  end  of  the  tube  is  due  to  the  many  folds  of  mucosa. 
The  mucous  layer  of  the  tube,  like  the  uterine  mucosa,  is  placed  directly 
upon  the  muscular  layer — there  is  no  intervening  submucosa  (Figs.  659,  660). 
The  surface  of  the  mucous  membrane  is  formed  of  a  layer  of  ciliated  cylindri- 
cal cells.  The  cells  are  somewhat  taller  than  those  lining  the  body  of  the- 
uterus  and  not  so  tall  as  those  lining  the  cervix  uteri.  Beneath  the  epithelial 
layer  the  mucosa  is  composed  of  "stroma  cells,"  very  much  like  those  found 


802  PELVIC   INFLAMMATION 

in  the  uterus,  except  slightly  smaller.  Between  the  stroma  cells  is  a  delicate- 
connective  tissue  framework.  There  are  found  also  capillary  blood  vessels 
and  small  lymph  .channels. 

There'  are  no  glands  in  the  tubal  mucous  membrane.  The  depressions 
which  look  like  glands  are  due  simply  to  the  folds  of  the  mucous  membrane 
(Figs.  661,  680).  As  there  are  no  glands  in  the  tube,  there  can  be  no  mucus 
secretion,  such  as  takes  place  in  the  uterus.  The  fluid  by  which  the  tube  is 
distended  in  certain  pathologic  conditions  is  inflammatory  exudate  and  not 
glandular  secretion. 

The  mucous  membrane  is  much  folded  longitudinally  (Fig.  505).     There 


\ 


Fig.   662.      Cross    Section    of    a   Normal    Fallopian    Tube,    near    the    Uterine    End.      (Penrose,    after    Beyea — 

Diseases  of   Women.) 

are  four  principal  folds  into  which  prolongations  of  the  muscular  tissue  take 
place.  There  is  no  muscular  tissue  in  the  many  smaller  folds.  In  the  inter- 
stitial portion  and  in  the  isthmus  the  folds  are  few  and  simply  longitudinal 
(Fig.  662),  but  in  the  outer  portion  of  the  tube  (the  ampulla)  they  become 
very  complex  and  fill  the  tube  with  folds  extending  in  every  direction  (Fig. 
663) — so  much  so  that  it  is  sometimes  difficult  to  decide  which  is  the  main 
canal  of  the  tube.  The  cilia  of  the  epithelium  project  into  the  lumen  of  the 
tube  and  by  their  movement  toward  the  uterus  aid  the  passage  of  the  ovum 
in  that  direction.  In  the  presence  of  this  delicate  and  much-folded  mucous 
membrane,  inflammation  in  the  tube  quickly  causes  serious  changes.  The 
cilia  are  lost,  the  folds  become  adherent  (Fig.  679),  pockets  of  serum  or  pus 


POINTS   IN    ANATOMY  803 

form,  and  the  picture  of  the  tubal  interior  may  be  so  changed  as  to  be  hardly 
recognizable. 

Vessels  and  Nerves.  The  blood  supply  of  the  tube  comes  from  the 
ovarian  artery  through  several  small  branches.  The  uterine  artery  helps  to 
supply  the  tube  in  some  cases.  The  veins  open  into  the  pampiniform  or 
ovarian  plexus  and  pass  into  the  broad  ligament.  The  lymphatics  join  with 
those  from  the  ovary.  The  nerve  supply  comes  from  the  pelvic  plexus  of  each 
side. 

Physiology.  The  primary  function  of  the  Fallopian  tube  of  each  side  is 
to  convey  ova  from  the  corresponding  ovary  to  the  uterus.  It  is  supposed  to 
require  several  days  for  the  ovum  to  pass  the  length  of  the  tube.     In  addi- 


'V.*"--^^  .*^'',''..»'' i*;'.'/^'*  y*  ,/"''«. 'v'-  V*V-**iv-"^-'-  '-     '•*  ,»*^».  '"'■•.' 


Fig.   663.      Cross   Section   of   the   Fallopian  Tube,    near   the   Fimbriated   Extremity.      (Penrose,    after   Beyea^ 

Diseases  of  Women.') 

tion  to  this,  the  tube  conveys  spermatozoa  in  the  opposite  direction,  and 
it  is  usually  in  the  tube  that  the  union  of  the  ovum  and  the  spermatozoon 
takes  place. 

The  mechanism  by  which  the  ovum  is  carried  from  the  ovary  into  the 
tube  is  complicated.  After  the  Graafian  follicle  in  the  ovary  bursts,  the  liquor 
folliculi  causes  the  ovum  to  adhere  slightly  to  the  surface  of  the  ovary.  Some 
of  the  fimbriae  are  in  contact  with  the  surface  of  the  ovary  and,  when  an 
ovum  comes  in  contact  with  one  of  them,  the  cilia  carry  it  towards  the  en- 
trance of  the  tube.  Besides  this  action  of  the  cilia  directly  on  the  ovum,  the 
constant  movement  of  all  the  cilia  causes  a  slight  current  of  peritoneal  fluid 
toward  the  interior  of  the  tube  from  all  directions.     This  helps  to  carry  the 


g04  PEL\^C    IXFLAMMxVTIOX 

ovnm  or  any  other  particles  into  the  tube.  The  fact  that  there  is  such  a 
current  towards  the  interior  of  the  tube  has  been  demonstrated  in  animals  by 
the  injection  into  the  pelvic  peritoneal  cavity  of  numerous  small  insoluble  par- 
ticles, which  were  foinid  later  in  the  tubes. 

It  has  been  suggested  that  the  fimbriated  extremity  of  the  tube  grasps 
the  ovary  when  an  ovum  is  discharged,  but  this  has  not  been  proved. 

Normal  Changes  in  the  Tube 

In  studying  the  anatomy  of  the  uterus  it  was  found  that  this  organ,  par- 
ticularly the  mucosa,  was  subject  to  normal  changes  under  three  conditions: 
namely,  menstruation,  pregnancy  and  the  menopause.  Xow,  in  the  Fallopian 
tube  also,  we  find  normal  changes,  due  to  menstruation,  to  pregnancy  and  to 
the  menopause.  Speaking  generally,  it  may  be  said  that  these  changes  are 
like  those  occurring  in  the  uterus,  but  less  marked. 

During  menstruation  there  is  congestion  of  the  tube  and  possibly  a  slight 
effusion  of  blood  into  the  interior  of  the  tube.  If  this  does  take  place,  how- 
ever, it  is  slight  and  is  of  no  importance  when  considering  the  source  of  the 
menstrual  blood.  Practically  all  of  the  menstrual  blood  comes  from  the  uterus. 
In  a  case  of  removal  of  the  uterus  by  operation  and  the  fastening  of  one  of 
the  tubes  in  the  vaginal  incision,  a  slight  bloody  flow  was  noticed  at  the 
menstrual  periods  for  a  few  months.  But  such  tubes  are  pathologic,  and  it 
is  an  open  question  whether  or  not  a  bloody  flow  would  take  place  from  a 
normal  tube. 

In  pregnancy  (normal  pregnancy,  not  tubal  pregnancy)  the  tube  wall 
and  mucous  membrane  become  thickened  and  the  folds  enlarged.  The  ves- 
sels also  become  larger,  especially  the  veins  and  lymphatics.  After  confine- 
ment the  tube  undergoes  involution  along  with  the  uterus. 

After  the  menopause  the  tube  shows  certain  senile  changes.  There  are 
disappearance  of  the  cilia,  diminution  in  the  size  of  the  tube,  shrinking  of 
the  connective  tissue,  and  shrinking  of  the  mucosal  folds.  The  tube  becomes 
smaller  and  firmer,  and  is  no  longer  a  functionating  structure. 

PELVIC  PERITONEUM 

The  pelvic  iDeritoneum  is  that  portion  of  the  wall  of  the  peritoneal  sac 
which  lies  in  the  peh'is.  It  is  attached  more  or  less  closely  to  the  pelvic  or- 
gans and  its  free  surface  comes  in  contact  with  the  peritoneal  surface  of  the 
intestines  as  they  move  about  in  the  lower  abdomen.  To  get  an  idea  of  the 
distribution  of  the  peritoneum  in  the  pelvis,  imagine  a  piece  of  thin  cloth 
laid  over  the  pelvic  organs  and  tucked  down  firmly  around  them  (Fig.  527). 

Starting  from  the  abdominal  wall,  the  peritoneum  passes  onto  the  blad- 
der, and  from  the  posterior  surface  of  the  bladder  to  the  uterus  (Fig.  3).  The 
height  of  the  abdomino-vesieal  fold  of  peritoneum  varies  much  with  the  vary- 


POINTS   IN    ANATOMY  805 

ing  size  of  the  bladder,  which  fact  is  of  much  importance  in  surgical  work. 
The  distance  to  which  the  peritoneum  extends  down  the  anterior  surface  of 
the  uterus  varies  considerably  in  different  persons.  Usually  it  extends  to 
the  level  of  the  internal  os  and  is  about  an  inch  above  the  anterior  vaginal 
fornix.  When  the  bladder  is  distended,  the  peritoneum  is  drawn  upward 
somewhat.  This  vesico-uterine  fold  of  peritoneum  forms  the  two  so-called 
"vesico-uterine  ligaments." 

The  peritoneum  then  folds  over  the  uterus  and  tubes  and  round  liga- 
ments, covering  these  structures  and  forming  the  ''broad  ligament"  of  each 
side.  All  the  jjosterior  surface  of  the  uterus  is  covered  with  peritoneum, 
except  that  portion  lying  within  the  vagina.  The  fold  of  peritoneum  ex- 
tends a  considerable  distance  below  the  point  of  attachment  of  the  vagina  to 
the  uterus  (Fig.  3)  before  being  reflected  on  to  the  rectum.  The  deep  pouch 
of  peritoneum  thus  formed  is  called  the  ''cul-de-sac  of  Douglas"  (Fig.  4). 
It  is  known  also  as  the  "posterior  cul-de-sac"  and  as  the  "posterior  peri- 
toneal pouch"  and  as  the  "recto-uterine  pouch."  This  posterior  cul-de-sac 
is  very  important  surgically.  A  collection  of  exudate  or  a  tumor  in  this  sit- 
uation can  be  easily  felt  from  the  posterior  vaginal  fornix.  This  is  the  point 
of  incision  in  posterior  vaginal  section,  and  it  is  usually  the  first  place  that 
the  jDeritoneal  cavity  is  entered  in  vaginal  hysterectomy. 

The  peritoneum,  as  it  is  reflected  from  the  uterus  to  the  rectum,  helps 
to  form  the  "sacro-uterine  ligaments."  The  sacro-uterine  ligaments,  two 
in  number,  one  on  each  side,  extend  backward  from  the  lower  part  of  the 
uterus  around  the  rectum  to  the  sacrum.  They  are  composed  of  connective  tis- 
sue, a  few  muscular  flbers  and  peritoneum.  The  cul-de-sac  of  Douglas  dips 
down  between  them  for  a  considerable  distance  (Fig.  4).  The  expanse  of 
peritoneum  extending  from  the  sacro-iliac  ligament  to  the  broad  ligament 
of  each  side  forms  a  kind  of  shelf.  The  two  together  are  sometimes  called 
the  "recto-uterine  shelves."  There  is  also  a  fold  or  shallow  pouch  of  peri- 
toneum on  each  side  between  the  Fallopian  tube  and  the  round  ligament.  A 
small  portion  of  the  uterus  at  the  sides  and  in  front  is  not  covered  with  peri- 
toneum (Fig.  512). 

The  structure  of  the  pelvic  peritoneum  is  much  the  same  as  of  peritoneum 
elsewhere.  It  is  a  very  thin  and  smooth  membrane,  formed  of  a  basis  of  deli- 
cate fibrous  and  elastic  tissue,  supporting  large  endothelial  cells. 

PELVIC  CONNECTIVE  TISSUE 

Between  the  peritoneum  and  the  recto-vesical  fascia  there  is  connective 
tissue.  This  is  distributed  so  as  to  fill  all  the  spaces  (Figs.  512,  664).  When 
it  is  necessary  for  organs  to  change  their  relation  to  each  other  in  physio- 
logic activity,  the  connection  is  open  and  loose  so  as  to  permit  free  move- 
ment and  much  stretching.  The  principal  collections  of  connective  tissue 
are   at  the  sides   of  and  in  front   of  the   cervix   uteri  and   at   the  base   of 


806 


PELVIC    INFLAMMATION 


each  broad  ligament.  The  areas  of  connective  tissue  are  exceedingly  rich  in 
lymphatics  and  veins.  Inflammation  taking  place  in  the  connective  tissue 
is  called  "pelvic  cellulitis." 

The  connective  tissue  about  the  uterus  is  often  spoken  of  collectively 
as  the  "parametrium"  or  parametrial  tissue,  and  inflammation  of  the  same 
is  accordingly  called  "parametritis."  This  is  a  very  convenient  term,  but 
is  likely  to  be  confounded  with  the  similarly  sounding  v/ord  "perimetritis." 


V\ 


Fig.  664.  The  Connective  Tissue  of  the  Pelvis.  Left  side  of  pelvis — section  through  cervix,  show- 
ing the  large  area  of  connective  tissue  at  side  of  cervix.  Right  side — section  at  higher  level,  showing  how 
the  broad  ligament  becomes  thinned,  leaving  only  a  small  amount  of  connective  tissue  at  side  of  corpus  uteri. 

The  latter  means  inflammation  of  the  structures  about  the  uterus,  particu- 
larly, however,  of  the  peritoneum  of  the  uterus  and  adnexa.  In  writing,  these 
two  terms  may  be  safely  used,  but  in  conversation  they  are  very  liable  to  be 
confounded,  as  they  sound  so  much  alike. 

It  was  formerly  supposed  that  nearly  all  inflammation  in  the  pelvis  out- 
side the  uterus  was  inflammation  of  the  connective  tissue  (i.  e.,  pelvic  cellu- 
litis), but  it  has  been  found  that  in  the  majority  of  cases  th©  inflammation 
invades  first  the  tube  and  later  the  peritoneum,  and  that  usually  the  involve- 
ment of  the  connective  tissue,  if  present  at  all,  is  a  late  development  and  of 


ACUTE    PELVIC    IXFLAMMATIOX  807 

only  secondary  importance.  There  are  exceptions  to  this  rule — for  example, 
those  inflammatory  conditions  resulting  from  tears  of  the  cervix  or  from 
operation  on  the  cervix.  Also  in  puerperal  infections,  particularly  strepto- 
coccic, the  inflammation  very  frequently  extends  directly  through  the 'wall 
of  the  uterus  in  the  pelvic  connective  tissue. 

ACUTE  PELVIC  INFLAMMATION 

Coming  now  to  the  consideration  of  the  disease  itself,  "we  find  that  pel- 
vic inflammation  may  be  acute  or  chronic.  Let  us  consider  first  the  acute 
variety. 

The  inflammatory  jDrocess  may  be  in  the  Fallopian  tubes  (salpingitis)  or 
in  the  o-varies  (oophoritis),  or  in  the  peritoneum  (pelvic  peritonitis),  or  in 
the  connective  tissue  (pelvic  cellulitis). 

Etiology 

The  cause  of  acute  pelvic  inflammation  is  infection.  The  infection  may  be 
with  the  ordinary  pus  germs  (staphylococcus  and  streptococcus)  or  vdth  the 
gonococeus.  Practically  every  case  of  primary  acute  pelvic  inflammation  in 
the  adult  can  be  traced  to  infection  from  labor,  from  abortion,  from  instru- 
mentation or  from  gonorrhea.  Secondary  inflammation  of  the  genital  organs 
may  be  caused  by  extension  from  an  inflammatory  focus  in  some  adjacent 
organ — e.  g.,  the  appendix  or  the  bladder. 

In  a  large  proportion  of  the  cases  of  pelvic  inflammation,  particularly 
the  gonorrheal  cases,  the  infection  extends  by  way  of  the  uterine  mucosa  to 
the  Fallopian  tubes,  and  through  the  tubes  to  the  peritoneum  and  other  pelvic 
structures.  In  puerperal  metritis  (streptococcic  or  staphylococcic)  the  in- 
fection more  often  extends  by  way  of  the  lymphatics  directly  through  the  wall 
of  the  uterus,  from  the  endometrium  to  the  connective  tissue  around  the  uterus, 
and  to  the  peritoneum.  Another  avenue  of  entrance  is  through  the  thrombosed 
sinuses  of  the  puerperal  uterus.  Infection  of  these  sinuses  leads  to  infective 
thrombosis  of  the  broad  ligament  veins,  resulting  in  broad  ligament  abscess 
or  general  pyemia  or  both. 

The  fact  that  nearly  every  case  of  pelvic  inflammation  is  due  to  an  in- 
fected endometritis  emphasizes  the  importance  of  checking  endometritis  at 
once  when  present,  and  of  preventing  it  whenever  possible. 

Pathology 

The  pathologic  changes  are  varied.  There  are  hardly  two  cases  exactly 
alike  and  the  same  case  presents  a  very  different  picture  at  different  periods. 
However  the  cases  may  be  divided  somewhat  into  classes,  as  follows : 

1.  Mild  Salpingitis.  The  inflammation  is  very  slight.  There  is  some 
round  cell  infiltration  of  the  wall  of  the  tube,  with  slight  thickening  and 


808  PELVIC   INFLAMMATION 

hardening,  and  a  few  fimbriae  bound  together.  Both  ends  of  the  tube  are 
open.  This  is  the  mildest  form  of  pelvic  inflammation,  and  as  a  rule  gives 
rise  to  very  few  symptoms.  A  more  severe  type  of  the  same  class  is  that  in 
which  both  ends  of  the  tube  are  occluded  and  the  fimbriae  are  matted  together, 
and  the  tube  distorted  and  often  adherent  to  the  ovary  or  to  some  other 
structure.  The  wall  of  the  tube  is  thickened,  but  the  cavity  contains  no  ap- 
preciable amount  of  fluid. 

2.  Salpingitis  with  Exudate.  In  the  cases  of  this  class  there  is  a  large 
amount  of  exudate,  binding  together  the  tubes,  ovaries,  intestines  and  uterus, 
but  there  is  no  distinct  collection  of  pus. 

3.  Pyosalpinx  (Tubal  Abscess.)  The  tube  is  distended  with  pus  (Fig.  392) 
and  there  are  the  usual  evidences  of  inflammation  within  and  without  the 
tube,  but  no  pus  outside  the  tube.  There  may  or  may  not  be  a  large  mass 
of  exudate."  In  exceptional  cases  the  infection  may  localize  in  the  ovary  in- 
stead of  in  the  tube,  causing  an  ovarian  abscess.  In  still  other  cases  the  ab- 
scess cavity  involves  both  the  tube  and  the  ovary,  forming  the  tubo-ovariarn 
abscess. 

4.  Diffuse  Suppuration  in  Pelvis.  In  this  fourth  class  the  pus  itself  has 
extended  outside  the  tube,  the  fibrinous  exudate  always  extending  before  it 
and  shutting  it  off  from  the  general  peritoneal  cavity.  This  may  result  simply 
in  an  abscess  low  in  the  pelvis,  which  can  be  easily  reached  and  evacuated 
from  below,  or  the  inflammation  may  extend  until  all  the  pelvic  organs  are 
bound  together  in  an  irregular  mass,  with  pus  lying  in  the  spaces  between 
them  and  burrowing  into  the  connective  tissue.  In  such  a  case  there  are 
present  all  the  lesions  of  pelvic  inflammation — salpingitis,  oophoritis,  peri- 
tonitis and  cellulitis. 

5.  Acute  Diffuse  Peritonitis.  In  cases  of  this  class  the  infection  is  so  viru- 
lent and  spreads  so  rapidly  that  but  little  limiting  exudate  is  formed.  The 
infection  quickly  involves  the  general  peritoneal  cavity  and  causes  a  fatal 
peritonitis.  This  is  an  nnusual  form  of  pelvic  inflammation  and  is  found 
principally  in  cases  of  severe  sepsis  following  labor  or  abortion. 

6.  Cellulitis  (Fig.  362).  This  is  largely  a  lymphangitis  of  the  connective 
tissue  about  the  uterus.  It  is  due  usually  to  the  streptococcus,  the  staphylo- 
coccus or  the  colon  bacillus — rarely,  if  ever,  to  the  gonococcus  alone.  Cellu- 
litis is  favored  by  deep  laceration  of  the  cervix,  Avhich  opens  up  the  con- 
nective area  beside  the  uterus.  Pelvic  cellulitis,  like  inflammation  of  con- 
nective tissue  elsewhere,  may  end  in  resolution  or  abscess  formation  or  gen- 
eral sepsis.  If  resolution  takes  place  or  if  an  abscess  forms  and  is  opened, 
the  inflammation  subsides,  leaving  only  infiltration  and  scar-tissue,  w^hich 
causes  but  few  symptoms  aside  from  distortion  of  the  parts.  The  inflamma- 
tion may,  however,  extend  to  the  peritoneum,  in  which  cases  there  are  added 
the  evidences  of  pelvic  peritonitis. 

7.  Septic  Thrombosis  (Fig.  665).  This  comes  from  infection  of  the  nor- 
mal thrombi  filling  the  uterine  sinuses  after  labor.    It  constitutes  a  severe  and 


ACUTE   PELVIC    INFLAMMATION 


809 


often  fatal  form  of  puerperal  sepsis.  In  the  effort  to  limit  the  infective  and 
destructive  process  in  the  sinus  or  vein,  Nature  causes  another  thrombus  to 
form  proximal  to  the  infected  one.  If  the  infection  extends  into  the  new 
thrombus,  a  portion  of  the  vein  proximal  to  that  in  turn  becomes  thrombosed. 
This  process  may  keep  on  until  the  veins  of  the  broad  ligament  become  exten- 


Fig.  665.  Pelvic  Thrombo-phlebitis.  The  left  broad  ligament  has  been  laid  open,  and  the  site  of  the 
upper  and  lower  group  of  thrombosed  veins  indicated.  The  right  ovarian  vein  is  shown  thrombosed  almost 
to  its  termination  in  the  vena  cava. 


810  PELVIC   INFLAMMATION 

sively  thrombosed.  If  the  infection  enters  through  the  upper  part  of  the 
uterus  (the  usual  placental  site),  it  affects  the  ovarian  veins  in  the  upper  part 
of  the  broad  ligament  (Fig.  665,  left  side).  If  it  enters  through  the  lower 
portions  of  the  uterus,  the  resulting  septic  thrombosis  affects  the  uterine 
veins  lower  in  the  broad  ligament  (Fig.  665). 

If  Nature  succeeds  in  limiting  the  process  to  this  region,  pockets  of  pus 
may  form  in  the  thrombosed  veins  and  break  into  the  connective  tissue,  form- 
ing a  pelvic  abscess,  which  can  be  recognized  and  opened.  If  Nature  does  not 
succeed  in  limiting  the  process,  it  extends  centrally — along  the  ovarian  veins 
(Fig.  665)  toward  the  vena  cava,  or  along  the  lower  veins  to  the  internal  iliac, 
the  common  iliac  and  finally  to  the  vena  cava.  When  the  common  iliac  is 
involved,  the  process  extends  downward  also  along  the  external  iliac  vein,  pro- 
ducing the  usual  signs  of  external  iliac  thrombosis  (so-called  "milk  leg").  It 
must  be  kept  in  mind,  however,  that  external  iliac  thrombosis  may  or  may  not 
be  septic  thrombosis,  many  cases  occurring  without  any  evidence  of  sepsis. 
At  any  stage  of  the  septic  process  in  the  veins,  infected  particles  may  be- 
come detached  and  pass  into  the  general  circulation,  giving  rise  to  metastatic 
foci  in  various  parts  of  the  body,  and  constituting  general  pyemia. 

Symptoms 

A  patient  with  acute  pelvic  inflammation  complains  of  pain  in  the  lower 
abdomen,  increased  by  movements,  such  as  walking  or  turning  over  or  sitting 
up.  She  is  usually  confined  to  bed.  There  may  be  moderate  fever  (101°  to 
103°)  or  there  may  be  high  fever  (105°),  the  high  temperature  being  found 
most  frequently  in  pelvic  infiammation  following  labor  or  miscarriage. 

There  is  usually  a  vaginal  discharge,  due  to  the  coincident  infiammation 
of  the  endometrium,  and  there  is  a  history  of  a  recent  labor  or  abortion,  or 
instrumentation  or  gonorrhea,  or  a  history  of  a  chronic  endometritis  due  to 
one  of  these  causes. 

On  abdominal  examination  the  lower  abdomen  is  found  to  be  tender  on 
pressure.  This  tenderness  may  be  confined  to  one  or  both  tubal  regions  or  it 
may  extend  over  all  the  lower  abdomen.  On  account  of  this  tenderness  the 
abdominal  muscles  are  held  more  or  less  tense,  thus  preventing  deep  palpation. 

In  the  vaginal  examination  the  character  of  the  discharge  is  determined, 
indicating  to  some  extent  the  etiology  of  the  trouble,  and  there  is  noticed  also 
the  presence  or  absence  of  evidences  of  recent  labor  or  miscarriage.  Manipu- 
lations in  the  upper  part  of  the  vaging^i^cause  pain.  This  tenderness  on  vaginal 
palpation  and  bimanual  palpation  is  found  both  in  the  body  of  the  uterus  and 
about  the  tube  of  one  or  both  sides.  If  a  mass  of  exudate  is  present,  it  may 
be  felt  to  one  side  of  the  uterus  or  behind  it.  If  the  exudate  is  low  in  the 
pelvis — for  example,  in  the  posterior  cul-de-sac  or  about  a  prolapsed  ovary  or 
tube — it  may  be  easily  felt  back  of  the  uterus  just  above  the  posterior  vaginal 
fornix.    If  the  exudate  is  situated  high  in  the  pelvis,  it  may  require  very  deep 


ACUTE   PELVIC    INFLAMMATION  811 

Ijimauual  palpation  to  detect  it,  and  the  deep  bimanual  palpation  may  be  im- 
possible at  first  on  account  of  the  tension  of  the  abdominal  muscles.  The  mass 
of  exudate  is  distinguished  by  its  being  more  resistant  (firmer)  than  the  sur- 
rounding tissues  and  more  tender  on  pressure.  The  exudate  may  extend  all 
around  the  uterus,  fixing  that  organ  as  though  plaster  of  Paris  had  been 
poured  into  the  pelvis  and  had  hardened  there.  In  these  cases  of  extensive 
distribution  of  the  exudate,  the  sensation  imparted  to  the  examining  fingers  is 
that  of  a  firm  roof  across  the  pelvis  just  above  the  vagina  (Fig.  401).  The 
uterus  projects  through  this  roof  of  exudate  and  is  held  firmly  by  it. 

If  there  is  a  collection  of  pus  of  considerable  size,  fluctuation  may  be  de- 
tected, the  soft  area  being  surrounded  by  a  firm  area  of  exudate  which  has 
not  yet  broken  doAvn.  If  there  is  only  a  small  collection  of  pus,  not  large 
enough  to  give  fluctuation,  its  presence  is  indicated  by  persistent  fever  and 
its  location  is  shown  by  a  point  of  marked  tenderness.  When  there  is  an  in- 
fianimatory  exudate  in  the  posterior  cul-de-sac,  fluctuation  may  in  some  cases 
be  detected  earlier  by  rectal  than  by  vaginal  examination,  the  rectal  finger 
being  able  to  palpate  the  posterior  surface  of  the  mass. 

In  septic  thrombosis  without  other  involvement  and  in  puerperal  pyemia 
there  may  be  no  evidence  of  pelvic  peritonitis  nor  of  pelvic  cellulitis — simply 
repeated  chills  and  high  fever  without  any  palpable  local  lesion  of  suf^cient 
extent  to  account  for  them.  There  is  tenderness  in  the  region  of  the  veins 
affected,  and  in  some  cases  distinct  induration  may  be  made  out,  particularly 
where  there  is  more  or  less  perivenons  inflammation.  If  the  infection  has 
come  through  the  upper  part  of  the  uterus  (which  is  the  usual  location  of  the 
placental  site  and  hence  of  the  area  of  penetration),  the  ovarian  veins  are  the 
ones  most  likely  to  be  affected.  In  many  cases  they  alone  have  been  found 
involved  (Fig.  665,  right  side).  When  the  infection  penetrates  the  lower  part 
of  the  uterus,  the  uterine  veins  and  broad  ligament  veins  generally  become 
affected,  and  later  the  internal  and  common  iliac  veins. 

Diagnosis 

The  diseases  that  may  be  confused  with  acute  pelvic  inflammation  and 
that  must  therefore  be  taken  into  consideration  in  the  differential  diagnosis 
are  as  follows : 

Acute  endometritis. 
Tubal  pregnancy. 
Appendicitis. 

A  tumor  which  has  become  gangrenous  from  twisted  pedicle. 
A  suppurating  tumor  (usually  a  dermoid  cyst  or  a  necrotic  fibroid). 
In  acute  endometritis  the  bimanual  examination  shows  that  the  tender- 
ness is  limited  to  the  uterus.    There  is  no  marked  tenderness  in  the  periuterine 
structures,  nor  is  any  mass  found  there. 

Tubal  Pregnancy  has  been  mistaken  so  many  times  for  ordinary  pelvic  in- 


812  PELVIC   INFLAMMATION 

flammatioii  that  the   differential  diagnostic   points   should  be   considered  in 
detail  (see  Tubal  Pregnancy). 

In  appendicitis  the  pain  is  more  likely  to  start  as  a  general  abdominal  pain^ 
the  point  of  greatest  tenderness  and  the  inflammatory  mass,  if  there  is  one, 
being  in  the  appendix  region  instead  of  in  the  tubal  region.  In  appendicitis 
also  there  is  frequently  a  history  of  stomach  or  bowel  disturbance  preceding 
or  associated  with  the  attack  of  pain,  while  in  salpingitis  there  is  usually  a 
history  of  uterine  disturbance. — dysmenorrhea,  prolonged  menstruation,  vag- 
inal discharge  and  other  indications  of  a  previous  or  coincident  uterine  dis- 
ease. In  girls  and  in  unmarried  women  an  attack  of  inflammation  low  in  the 
right  side  is  much  more  likely  to  be  appendicitis  than  salpingitis.  In  some 
patients  both  structures  are  involved. 

In  all  right-sided  inflammations  keep  in  mind  appendicitis.  One  having 
liis  mind  too  intent  on  pelvic  disease  may  overlook  this.  This  fact  is  very 
well  illustrated  by  a  case  in  which  the  author  was  called  in  consultation  by  a 
physician  in  this  city.  A  few  days  before,  the  physician  had  operated  for 
laceration  of  the  cervix.  Following  the  operation  the  patient  developed  pain 
in  the  lower  abdomen  and  rapid  pulse,  and  nausea  and  fever.  The  symptoms 
were  persistent  and  progressive,  and  in  three  days  the  patient's  condition 
became  alarming.  Fearing  acute  pelvic  inflammation  from  infection  at  the 
site  of  operation,  he  asked  for  a  consultation.  Examination  showed  the 
cervical  wound  to  be  in  good  condition  and  nothing  could  be  found  in  the 
immediate  vicinity  of  the  uterus  to  account  for  the  serious  symptoms.  But 
on  searching  further  it  was  evident  the  patient  had  appendicitis,  with  peri- 
tonitis. The  vomiting  and  intraabdominal  disturbance  following  anesthesia 
had  evidently  stirred  to  renewed  activity  an  old  focus  of  inflammation  about 
the  appendix.  The  patient  had  general  peritonitis  at  the  time  when  seen  by 
the  author  and  she  died  before  the  consent  of  her  people  to  an  operation  could 
be  secured. 

In  the  case  of  a  tumor  which  is  gangrenous  from  tAvisted  pedicle,  the  tu- 
mor has  existed  a  long  time,  and  one  can  usually  get  a  history  of  pelvic  dis- 
turbance caused  by  it,  and  in  some  cases  a  clear  history  of  a  tumor  can  be 
obtained.  When  the  turning  of  the  tumor  with  torsion  of  its  pedicle  takes 
place,  that  causes  a  sudden  onset  of  serious  symptoms — severe  pain,  extending^ 
more  or  less  throughout  the  abdomen,  and  symptoms  of  shock.  Later,  as  the 
tumor  begins  to  degenerate  on  account  of  the  cessation  of  its  blood  supply, 
local  peritonitis  comes  on,  causing  fever.  The  local  peritonitis  may  spread 
and  become  general  peritonitis,  and  at  this  stage  the  origin  of  the  trouble  is 
much  obscured.  Absence  of  evidence  of  infected  endometritis  is  another 
important  point  in  the  differential  diagnosis  of  this  condition  from  ordinary 
pelvic  inflammation,  as  is  also  the  absence  of  fever  at  the  onset  of  the  trouble 
and  for  several  hours  afterward. 

A  suppurating  tumor  is  usually  a  dermoid  cyst,  coiniected  with  the  ovary, 
and  hence  gives  rise  to  a  nuiss  in  the  same  region  in  which  an  inflammatory 


TREATMENT    OF    ACUTE   PELVIC    INFLAMMATION  813 

mass  from  salpingitis  would  be  found.  When  suppuration  takes  place  in  an 
ovarian  dermoid,  there  is  resulting  local  peritonitis,  with  fixation  of  the  mass 
hy  adhesions.  The  fever  and  pelvic  pain  and  marked  tenderness  on  examina- 
tion all  tend  to  further  confusion  with  ordinary  pelvic  inflammation,  making 
the  differential  diagnosis  often  very  difficult  and  sometimes  impossible.  If 
the  patient  is  a  girl,  or  a  woman  who  has  never  been  pregnant  nor  had  any 
uterine  infection,  the  probability  is  in  favor  of  dermoid  tumor  and  against 
salpingitis.  Two  other  points  in  favor  of  the  mass  being  a  dermoid  tumor 
are  (1)  a  history  of  pelvic  disturbance,  pointing  to  the  existence  of  a  tumor 
before  the  acute  symptoms  developed,  and  (2)  the  absence  of  vaginal  dis- 
•charge  and  other  evidences  of  uterine  infection; 

Necrosis  or  suppuration  within  a  uterine  fibroid  presents  the  evidences  of 
inflammation  added  to  evidences  (past  and  present)  of  a  fibroid  tumor. 

Treatment 

In  the  treatment  of  acute  pelvic  inflammation  (acute  salpingitis,  acute 
•oophoritis,  acute  pelvic  peritonitis,  acute  pelvic  cellulitis,  and  all  combina- 
tions of  these  lesions),  there  are  employed  certain  measures  that  may  be  called 
general  measures,  because  they  are  applicable  to  all  cases.  There  are  em- 
ployed also  other  measures  that  may  be  called  special  measures,  because  they 
are  applicable  to  special  conditions  only. 

GENERAL  MEASURES 

The  general  measures  indicated  in  the  treatment  of  practically  all  cases 
of  acute  pelvic  inflammation,  are  as  follows: 

1.  Rest.  Keep  the  patient  in  bed.  If  the  inflammation  is  severe,  she 
should  use  the  bed-pan  and  should  not  be  permitted  to  get  up  to  a  vessel  be- 
side the  bed. 

2.  Laxatives.  The  patient  should  have  one  or  two  good  bowel  movements 
daily. 

3.  Hot  Vaginal  Douches  every  six  to  twelve  hours,  the  frequency  depend- 
ing on  the  severity  of  the  inflammation. 

4.  Applications  to  the  Lower  Abdomen.  The  hot  applications  are  usually 
most  effective  in  relieving  pain.  In  exceptional  cases  the  cold  applications 
give  more  relief. 

5.  Sedatives.  If  the  pain  is  persistent  in  spite  of  the  measures  already 
mentioned,  mild  sedatives  should  be  used,  such  as  the  bromides  or  prepa- 
rations containing  viburnum  prunif  oliuni.  Avoid  morphine  unless  -the  pain  is  so 
severe  as  to  make  its  use  imperative,  for  it  disturbs  the  stomach,  checks  the 
secretions  and,  in  addition,  masks  the  pain  to  such  an  extent  as  to  interfere 
with  our  knowledge  of  the  progress  of  the  disease.  The  coal-tar  antipyretics 
are  also  usually  best  avoided  for  the  reason  that  they  mask  the  fever.     The 


814 


PELVIC   INFLAMMATION 


pain  and  the  fever  are  two  important  guides  as  to  the  progress  of  the  in- 
flammation, and  hence  should  not  be  masked  more  than  necessary.  If  there 
is  much  fever,  cool  sponging  will  give  comfort  and  reduce  the  temperature 
and  stimulate  the  patient,  and  its  effect  can  be  more  accurately  gauged  than 
that  of  internal  antipyretics.  If  there  is  much  pain,  of  course  sedatives  must 
be  given  in  sufficient  quantity  to  give  rest.  Codeine  phosphate  in  1/2  gr.  to  % 
gr.  doses  disturbs  the  stomach  less  than  morphia  and  usually  gives  relief.  If 
not  sufficient,  then  morphia  will  be  necessary.  Whenever  sedatives  or  anti- 
pyretics are  given,  their  effect  must  be  allowed  for  in  reckoning  the  extent 
or  progress  of  the  inflammation. 

SPECIAL  MEASURES 

The  special  measures,  indicated  in  certain  cases  of  acute  pelvic  inflamma- 
tion, are  most  conveniently  presented  by  stating  the  particular  conditions  for 
which  they  are  used. 


Fig.  666.  Instruments  for  Opening  Pelvic  Abscess:  a,  self-retaining  speculum;  b,  perineal  retractor; 
c,  vaginal  dressing  forceps;  d,  uterine  tenaculum  forceps;  e,  two  long  artery  forceps;  /,  long,  curved,  blunt 
scissors;  g,  long,  curved,  sharp-pointed  scissors;  h,  needle  holder;  i,  needle  and  ligature,  for  use  in  case  of 
unusual  hemorrhage;  /,  drainage  tube  with  cross-piece. 


1.  If  the  infection  has  followed  labor  or  abortion,  it  is  desirable  to  have 
the  interior  of  the  uterus  clean.  Exploration  of  the  interior  of  the  uterus  with 
the  finger  or  rarely  with  the  curet  may  become  necessary  but  it  is  better 
avoided  except  in  cases  of  severe  hemorrhage  (see  page  136). 

2.  If  the  infection  has  taken  place  through  an  operation  woiind  of  the 
cervix,  remove  the  sutures  so  as  to  give  free  drainage  to  the  inflamed  area. 

3.  If  a  collection  of  pus  can  be  felt  low  in  the  pelvis  open  and  drain  it  by 
vaginal  incision.  It  requires  care  to  open  a  deeply  placed  pelvic  abscess 
widely  and  safely,  particularly  if  the  pocket  of  pus  is  small.     The  rectum, 


TREATMENT    OF   ACUTE   PELVIC    INFLAMMATION 


815 


uterus,  uterine  vessels,  ureter  or  bladder  may  be  injured,  or  the  abscess  may 
not  be  opened  and  drained  thoroughly  enough  to  effect  a  cure.  The  instru- 
ments required  are  shown  in  Fig.  666. 

The  steps  in  the  operation  are  as  follows: 

a.  Examination  Under  Anesthesia.— After  the  patient  is  anesthetized  and 
the  vagina  thoroughly  cleansed,  make  a  bimanual  examination  to  determine 
the  size  and  relations  of  the  inflammatory  mass  and  what  portion  of  it  is 
fluctuating.  Determine  also  whether  or  not  the  corpus  uteri  is  forward  and 
hence  out  of  the  way  of  the  operative  work. 

b.  Incision  Through  Vaginal  Wall. — Introduce  the  self -retaining  speculum 
or  a  simple  perineal  retractor,  swab  out  the  vagina  again  with  an  antiseptic 
solution,  cat(ih  the  posterior  lip  of  the  cervix  with  a  tenaculum  forceps  and 


Fig.  667.  Incision  Through  Vaginal  Wall.  The 
retractor  has  been  introduced,  the  cervix  caught 
with  a  tenaculum  forceps,  and  the  vaginal  wall 
clipped  through  just  back  of  the  cervix. 


Fig.  668.  Blunt  Dissection  Through  Connec- 
tive Tissue.  The  retractor  has  been  removed  to 
permit  the  fingers  to  be  introduced  into  the  vaginal 
incision,  and  dissection  is  now  being  made  through 
the  connective  tissue  with  fingers  and  blunt  scissors, 
as  described  in  the  text.  The  arrows  show  the 
direction  of  the  dissection  (between  abscess  and 
uterus  and  not  between  abscess  and  rectum),  and 
each  arrow  may  be  taken  to  represent  a  forward 
thrust  of  the  blunt  scissors  beyond  the  end  of  the 
finger. 


raise  the  cervix  so  as  to  expose  the  posterior  vaginal  vault.  Now,  with  a  long 
forceps  (Fig.  667),  take  firm  hold  of  the  posterior  vaginal  wall  a  short  dis- 
tance back  of  the  cervix  and  then  with  a  scissors  or  knife  clip  through  the  vag- 
inal mucosa,  between  the  forceps  and  the  cervix  (Fig.  668).  The  author  usually 
uses  the  same  blunt  curved  uterine  scissors  with  which  the  subsequent  dissection 


816 


PELVIC   INFLAMMATION 


is  made.  By  a  little  traction  on  the  forceps  a  ridge  of  mucosa  is  raised  which 
is  easily  clipped  through  with  the  scissors.  The  opening  is  then  lengthened 
to  each  side,  curving  slightly  around  the  cervix,  until  it  is  an  inch  to 'an  inch 
and  a  half  long.  This  gives  an  opening  into  the  connective  tissue  back  of  the 
cervix. 

c.  Blunt  Dissection  Through  Connective  Tissue. — This  is  most  safely  and 
conveniently  accomplished  by  the  sense  of  touch  alone.  The  specuhim,  or 
perineal  retractor,  is  removed  and  two  fingers  are  introduced  into  the  vagina, 
one  of  the  fingers  being  carried  into  the  wound  back  of  cervix.  With  this 
finger,  blunt  dissection  is  made  upward  through  the  connective  tissue,  keep- 
ing close  to  the  wall  of  the  cervix,  which  is  distinguished  by  its  greater .  hard- 


■  Fig.  669.  Puncturing  the  Abscess  Wall.  The 
sharp-pointed  scissors  have  been  introduced  into  the 
mass  under  the  guidance  of  the  finger,  and  then 
opened    widely. 


Fig.  670.  Drainage  Tube  in  Place.  The  cross- 
piece  is  to  prevent  the  tube  slipping  out.  The  tube 
is  cut  off  about  midway  of  the  vagina.  The  gauze 
packing  extends  into  the  connective  tissue  area  about 
the   tube,   but   not   into   the   abscess   cavity. 


ness.  This  dissection  is  facilitated  by  introducing  the  closed  blunt  scissors 
some  distance  ahead  of  the  finger  as  shown  in  Fig.  668,  and  then  opening  the 
scissors  widely.  The  finger  is  introduced  into  the  opening  thus  made  in  the 
connective  tissue,  and  the  scissors  are  again  introduced  beyond  the  finger  and 
opened  widely.  In  this  way  a  wide  tract  may  be  made  rapidly  through  the 
connective  tissue,  and  it  may  be  made  safely,  provided  the  operator  keeps 
close  to  the  cervix  as  indicated  in  Fig.  668.  Each  arrow  in  this  illustration 
may  be  taken  to  represent  a  forward  thrust  of  the  blunt  scissors  beyond  the 
end  of  the  finger.  Notice  that  the  direction  of  the  dissection  carries  it  between 
the  uterus  and  the  abscess  instead  of  between  the  rectum  and  the  abscess, 


TREATMENT    OF    ACUTE    PELVIC    INFLAMMATION  '817 

and  thus  the  danger  of  tearing  into  the  rectum  is  avoided.  On  the  other 
hand,  the  dissection  must  not  be  carried  into  the  cervix  uteri.  Involvement 
of  the  tcugh  tissue  of  the  cervical  wall  is  indicated  by  the  blunt  dissection 
becoming  very  difficult  while  still  some  distance  from  the  abscess. 

d.  Puncturing  the  Abscess  Wall. — When  the  wall  of  the  abscess  is 
reaches,  further  advance  by  blunt  dissection  becomes  very  difficult  or  impos- 
sible, rhis  wall  of  dense  infiltration  blocking  further  advance  is  especially 
marked  in  a  long-standing  abscess,  but  it  is  present  in  acute  abscesses  also  to 
a  considerable  extent.  The  blunt  scissors  are  now  exchanged  for  the  sharp- 
pointed  scissors  (Fig.  669),  and  with  these  the  puncture  is  made  into  the  cen- 
ter of  the  inflammatory  mass.  Care  must  be  taken  to  make  sure  that  the  punc- 
ture will  not  extend  into  the  rectum.  A  hard  fecal  mS;SS  in  the  rectum  may 
be  mistaken  for  a  portion  of  the  inflammatory  mass,  or  a  gas-distended  part 
of  the  rectum  may  simulate  the  soft,  elastic  feel  of  a  fluctuating  mass,  or 
a  collapsed  pocket  of  the  rectum  may  project  between  the  vaginal  vault  and 
the  abscess.  In  Fig.  667  this  dangerous  proximity  of  the  rectal  wall  to  the 
operative  tract  is  well  shown.  If  the  line  of  blunt  dissection  is  kept  close  to 
the  uterus,  the  abscess  wall  is  reached  close  to  the  uterus,  with  a  considerable 
part  of  the  abscess  lying  between  the  point  of  puncture  and  the  rectum,  as 
sho^^ai  in  Fig.  668.  Should  there  be  any  doubt  about  this,  leave  the  scissors 
in  the  tract  and,  with  gloved  fingers,  make  an  examination  per  rectum.  This 
examination  gives  a  clear  idea  of  the  amount  of  tissue  between  the  point  of 
intended  puncture  (indicated  by  the  end  of  the  scissors)  and  the  nearest  por- 
tion of  the  rectal  wall. 

After  the  curved,  sharp-pointed  scissors  have  been  pushed  into  the  center  of 
the  mass,  they  are  opened  widely  and  then  withdrawn  while  still  wide  open. 
This  makes  a  large  tract  into  the  abscess.  One  or  two  fingers  are  then  introduced 
into  the  cavity  and  its  wall  explored  for  secondary  pus  pockets.  If  a  fluctuating 
area  is  found,  it  may  be  opened  by  the  flnger,  dressing  forceps  or  scissors,  care 
being  taken  to  avoid  wounding  the  rectum  or  mistaking  an  adherent  knuckle  of 
intestine  for  a  fluctuating  pus  pocket.  While  an  adherent  loop  of  intestine  may 
feel  soft  and  elastic,  it  never  presents  the  tense  fluctuation  and  resistance  of  a 
pus  pocket,  unless  obstructed.  In  this  palpation  of  the  interior  of  the  abscess 
cavity,  all  manipulation  should  be  made  gently,  so  as  not  to  break  through  the 
protecting  roof  of  exudate. 

e^  Drainage. — After  all  pus  pockets  are  opened,  introduce  a  good-sized 
drainage  tube  into  the  abscess  cavity  (Fig.  670).  Swab  out  the  vagina  and 
pack  it  lightly  with  antiseptic  gauze.  The  upper  end  of  the  gauze  should  be 
packed  rather  firmly  into  the  connective  tissue  about  the  tube,  so  as  to  stop  any 
bleeding  there.  The  gauze  is  to  be  packed  only  a  short  distance  into  the  wound, 
so  that  it  will  not  pull  out  the  tube  when  it  is  removed,  for  the  rubber- tube  is 
to  be  left  in  place  until  the  cavity  is  nearly  obliterated  by  granulation,  Avhich 
requires  two  to  six  weeks. 

The  drainage  tube  will  not  stay  in  place  without  some  special  device.     A 


818 


PELVIC   INFLAMMATION 


very  convenient  expedient  is  to  introduce  a  short  piece  of  a  smaller  tube  cross- 
wise througli  holes  cut  near  the  end  of  the  main  tube  (Fig.  671).  This  drain- 
age-tube is  introduced  into  the  abscess  cavity  by  grasping  it  with  a  long  forceps 
as  shown  in  the  illustration.  When  in  place,  the  forceps  are  removed  and  the 
cross-piece  resumes  its  original  position,  and  thus  prevents  the  tube  slipping  out 
of  the  cavity.  When  it  is  desired  to  remove  the  tube,  slight  traction  causes  the 
ends  of  the  cross-piece  to  fold  up,  and  the  tube  is  removed  with  but  little  pain. 
Another  method  of  forming  a  cross-piece  on  the  tube  is  shown  in  Fig.  672,  and 
such  a  tube  is  shown  in  place  in  Fig.  670.    After  the  tube  is  in  place,  its  lower 


ho 


Fig.  671.  Showing  how  to  arrange  a  Drainage  Tube  with  a  small  cross-piece  at  the  end  to  keep  the 
tube  from  slipping  out  of  the  cavity.  To  introduce  the  tube,  the  cross-piece  is  turned  up  on  each  side  and 
the  end  of  the  tube  is  grasped  with  a  forceps,  as  shown  to  the  right  of  the   illustration. 


end  is  cut  off  about  the  middle  of  the  vagina  and  the  vaginal  gauze  packing  is 
distributed  around  it.  If  the  tube  is  allowed  to  extend  outside  the  vaginal 
entrance,  it  causes  more  or  less  irritation  of  the  external  surfaces,  and  if  it  is  cut 
too  short  it  may  slip  up  into  the  abscess  cavity  and  be  lost. 

Errors  to  Avoid.  One  error  to  avoid  is  irrigation  of  the  cavity.  The  free 
opening  of  the  abscess  relieves  the  tension,  and  this,  with  the  subsequent  drain- 
age, is  all  that  is  required.  Furthermore,  if  a  stream  of  fluid  is  run  into  the 
cavity,  it  may  break  through  some  weak  place  in  the  protecting  wall  and  cause 
infection  of  the  general  peritoneal  cavity.    Irrigation,  therefore,  is  not  only  un- 


TREATMENT    OF    ACUTE   PELVIC    INFLAMMATION 


819 


necessary,  but  dangerous,  and  may  cause  fatal  peritonitis  in  a  case  that  would 
have  recovered  promptly  under  simple  drainage. 

Another  error  to  avoid  is  dependence  on  gauze  drainage.  A  considerable 
proportion  of  failures  and  secondary  operations  are  due  to  this.  When  there 
is  a  distinct  abscess  cavity,  there  will  necessarily  be  discharge  for  some  time,  and 
this  discharge  should  find  ready  exit  through  tube  drainage.  Gauze  packing 
is  very  good  for  checking  bleeding  or  for  holding  the  tract  open  for  a  few  days, 
but  it  is  not  satisfactory  when  prolonged  drainage  is  necessary,  and  prolonged 
drainage  is  necessary  in  practically  all  cases  where  a  distinctly  walled  abscess 
has  formed.  In  the  crowded  and  contracting  tissues  of  the  pelvis,  tube  drainage 
is  the  only  kind  that  will  keep  the  drainage  tract  open  satisfactorily  and  con- 
veniently for  the  length  of  time  required  for  a  large  cavity  to  become  obliterated 
by  granulation.  And  the  best  time  to  place  this  tube  drain  satisfactorily  is  when 
the  patient  is  under  the  anesthetic  and  the  abscess  just  opened. 


Fig.   672. 


Another  method  of  arranging  a  cross-piece  on  the  end  of  a  Drainage  Tube  to  keep  the  tube  from 
slipping  out   of  the  cavity.      (Reed — Textbook  of   Gynecology.) 


Variations.  In  a  case  of  tubal  abscess  where  the  pus  has  not  yet  escaped 
from  the  Fallopian  tube,  the  cul-de-sac  of  Douglas  is  opened  before  the  abscess 
proper  (tube  wall)  is  reached.  The  cul-de-sac  may  or  may  not  be  shut  off  from 
the  general  peritoneal  cavity  by  adhesions.  In  some  such  cases  a  small  amount 
of  serous  fluid  escapes  when  the  cul-de-sac  is  opened.  Exploring  this  non-puru- 
lent cavity,  the  finger  encounters  the  distended,  fluctuating  tube,  which  is  then 
opened,  with  a  resulting  free  discharge  of  pus.  Two  points  of  importance  in  such 
a  case  are :  flrst,  to  make  a  free  opening  in  the  wall  of  the  distended  tube,  and, 
second,  to  place  the  end  of  the  drainage  tube  inside  the  affected  tube  and  not 
simply  in  the  cul-de-sac. 

In  draining  a  broad  ligament  abscess,  avoid  opening  the  peritoneal  cul-de-lac 
Such  opening  is  unnecessary  and  is  dangerous,  for  the  uninfected  cul-de-sac  is 
not  likely  to  be  walled  off  from  the  general  peritoneal  cavity.  In  operating  in  a 
case  where  the  inflammatory  mass  is  situated  laterally,  the  vaginal  wall  is  cut 


820  PELVIC   INFLAMMATION 

through  as  before,  and  then  the  dissection  is  directed  laterally  between  the  layers 
of  the  broad  ligament.  In  this  way  a  collection  of  pus  situated  even  in  the  upper 
part  of  the  broad  ligament  may  be  drained  freely  without  opening  the  peritoneal 
cavity. 

In  an  acute  inflammatory  mass  without  pus  it  may  in  certain  cases  be  ad- 
visable to  drain.  In  a  considerable  proportion  of  inflammatory  masses  it  is 
impossible  to  say  positively  before  operation  whether  or  not  there  is  a  pocket  of 
pus  in  the  mass.  If  general  symptoms  are  threatening  and  the  mass  is 
increasing  in  size  and.  tenderness,  drainage  is  advisable — on  the  general  surgical 
principle  of  immediate  drainage  of  an  acute  infected  focus  that  Nature  is  failing 
to  limit.  In  such  a  case  the  steps  are  the  same  as  for  a  distinct  abscess — ^viz., 
blunt  dissection  through  the  connective  tissue,  puncture  to  the  center  of  the 
mass  with  sharp-pointed  scissors  and  enlargement  of  the  tract  by  withdrawing 
the  scissors  wide  open.  The  interior  of  the  mass  is  then  palpated  with  one  or 
two  fingers  and  perhaps  opened  further  in  various  directions.  If  no  pus  is 
found,  the  cavity  is  packed  lightly  with  gauze.  As  there  is  no  distinct  pus 
cavity,  there  is  no  indication  for  tube  drainage.  However,  if  when  the  gauze  is 
removed  after  two  or  three  days  a  free  purulent  discharge  is  present  (due  to 
an  adjacent  pus  pocket  opening  into  the  cavity  or  to  the  advancement  of  the 
inflammatory  process  to  the  point  of  suppuration),  then  a  small  drainage  tube 
with  cross-piece  should  be  introduced  at  the  time  the  gauze  is  removed.  If  no 
pus  is  present,  no  tube  drain  is  required — simply  vaginal  douches,  with  or 
without  light  gauze-packing  of  the  tract,  as  preferred.  The  author  has  seen,  in 
a  number  of  instances,  marked  relief  from  pain  and  rapid  resolution  follow 
this  puncture  and  drainage  of  an  acute  inflammatory  mass  without  distinct  pus 
formation. 

f.  After-ireatmeni. — In  the  after-treatment  of  an  opened  pelvic  abscess  the 
two  important  points  are  (1)  continued  free  drainage  until  the  cavity  has  been 
practically  obliterated  by  granulation,  and  (2)  avoidance  of  unnecessary  irri- 
tation, such  as  repeated  packing  or  probing  of  the  tract,  or  frequent  syringing 
of  the  abscess  cavity. 

■■  Neglect  of  the  first  point  -is  the  cause  of  the  failure  in  a  large  proportion  of 
the  cases  where  the  abscess  reforms  and  requires  secondary  operation — that 
is,  when  the  case  has  been  well  chosen  and  is  really  suitable  for  vaginal  drain- 
age. The  neglect  of  the  second  point  causes  much  unnecessary  pain  and  irrita- 
tion by  repeated  probing  and  packing  of  the  suppurating  tract,  and  also  con- 
tributes to  failure  by  early  removal  of  the  well-placed  rubber  drainage  tube, 
which  is  the  only  efficient  method  of  continued  drainage  in  this  situation. 

The.  gauze  in  the  vagina  is  removed  in  one  or  two  days  and  after  that  an 
aiitii^eptic  vaginal  douche  is  given  one  to  three  times  daily,  the  frequency  depend- 
ing on  the  amount  of  discharge.  The  patient  is  kept  in  bed  for  a  week ;  and  after 
that,  if  there  is  no  pain  or  fever,  she  is  allowed  to  be  up  and  about.  If  the  tube 
stops  up  at  any  time,  it  may  be  cleared  out  by  injecting  some  hydrogen  peroxide 


TREATMENT    OF    ACUTE   PELVIC    IXFLAMMATIOX  821 

into  it.  If  this  does  not  clear  it,  it  is  probably  stopped  by  a  slough  or  fibrinous 
mass.  Eemove  the  tube  and,  after  clearing  it  thoroughly,  reintroduce  it  or  a 
smaller  one.  For  changing  the  tube  or  for  any  manipulation  about  the  opening 
back  of  the  cervix,  the  Sims  posture  is  more  convenient  than  the  dorsal  posture 
(see  page  119). 

The  tube  should  be  left  in  place  as  long  as  there  is  a  cavity  to  discharges- 
varying  in  different  cases  from  two  to  six  weeks.  If  after  the  large  tube  has 
been  in  for  a  week,  the  patient  complains  of  pain  on  bowel  movement  or  other 
pain  in  pelvis,  remove  the  tube  and  introduce  a  smaller  one.  As  the  abscess 
cavity  contracts,  it  is  necessary  to  reduce  the  size  of  the  tube  aud  cross-piece 
sufificiently  to  prevent  pressure-ulceration  of  the  rectal  wall.  Continue  the 
douches  for  at  least  a  week  after  tube  is  removed  and  all  discharge  has  ceased. 

4.  If  a  collection  of  pus,  or  a  mass  of  exudate  that  may  or  may  not  contain 
pus,  is  found  high  in  the  pelvis,  do  not  disturb  it  during  the  acute  attack  unless 
the  patient 's  life  is  threatened  by  the  severity  of  the  process.  Avoid  abdominal 
operation  in  the  primary  acute  attack,  if  possible.  There  are  two  reasons  for  this 
— first,  the  patient  may  recover  completely  under  the  minor  measures  (rest, 
laxatives,  hot  douches,  curettage),  and,  second,  if  extirpation  of  the  mass  is 
finally  necessary,  it  can  be  carried  out  later  with  much  less  danger  to  the  patient. 
There  is  no  less  danger  later  because  collections  of  pus  in  the  pelvis  become  less 
virulent  after  a  time.  In  many  old  pelvic  abscesses  the  bacteria  are  dead  and  the 
pus  sterile,  and  extensive  contamination  of  the  field  of  operation  fails  to  cause 
peritonitis.  If,  on  the  other  hand,  the  operation  is  done  early  while  the  bacteria 
are  still  virulent,  contamination  of  the  field  is  very  likely  to  result  in  fatal 
peritonitis. 

In  mentioning  the  fact  that  the  majority  of  inflammatorj^  masses  in  the 
pelvis  become  sterile  after  a  time,  attention  must  be  called  to  an  exceptional 
class — namely,  the  streptococcal  cases.  In  the  streptococcal  masses  automatic 
sterilization  or  attenuation  is  uncertain.  Though  sometimes  present,  its  occur- 
rence can  never  be  counted  on.  In  streptococcal  masses  the  bacteria  have  been 
found  active  and  virulent  after  long  periods — even  years.  Consequently,  in  these 
cases  intraperitoneal  operation  is  never  safe.  The  persistence  of  virulence  in 
streptococcal  cases,  h,ow  to  recognize  them  before  operation,  what  to  do  for  them 
when  operation  is  necessary,  and  other  points  of  interest  are  considered  in  detail 
under  chronic  inflammatory  masses  in  the  pelvis  (see  pages  853  to  859). 

In  acute  inflammatory  masses,  whether  streptococcal  or  gonococcal,  intra- 
peritoneal operation  is  to  be  avoided.  Those  abscesses  situated  high  are  the  ones 
now  under  consideration.  If  the  symptoms  are  urgent,  and  the  pocket  of  pus 
can  not  be  reached  and  drained  per  vaginam,  it  may  be  possible  to  drain  .it 
extraperitoneally  by  operation  above  Poupart's  ligament.  This  is  entirely  pracr 
tical  when  the  abscess  is  situated  in  the  broad  ligament  (as  most  streptococcal 
abscesses  are)  and  it  has  proved  a  life-saving  measure  in  several  instances.  The 
route  followed  is  the  same  as  for  ligation  of  the  external  iliac  arterv.    In  all  but 


822 


PELVIC    IXFLA3IMATI0X 


exceptional  cases,  however,  an  abscess  in  any  part  of  the  broad  ligament  can  be 
reached  and  drained  satisfactorily  per  vaginam  by  any  one  familiar  with  vag- 
inal work. 

5.  If  the  inflammation  takes  the  form  of  a  rapidly-spreading  peritonitis, 
with  little  or  no  limiting  exudate,  or  in  spite  of  limiting  exudate,  the  peritoneal 
cavity  should  be  opened  and  drained,  either  by  vaginal  section  or  abdominal 
section  or  both.  Such  cases  are  seen  principally  in  pelvic  inflammation  following 
labor  or  miscarriage  and  constitute  a  severe  type  of  puerperal  sepsis.  The  in- 
flammation may  have  extended  directly  through  the  wall  of  the  uterus  to  the 
peritoneum,  or  first  to  the  Fallopian  tubes  and  from  there  to  the  peritoneum. 
In  either  case  there  is  a  rapidly  spreading  peritonitis  of  virulent  type  and  the 


Fig.   673. 


^'aginal   Section   for   Acute    Pelvic   Inflammation,   showing  tlie    gauze   paclving   in 
Operative  Gynecology.) 


lace.      (Kelly — 


patient  is  in  a  desperate  condition.     There  are  two  methods  of  dealing  with 
these  cases : 

Vaginal  Section. — Open  into  the  pelvic  cavity  by  posterior  vaginal  section 
and  let  the  infected  peritoneal  fluid  run  out.  Palpate  the  uterus  and  appendages, 
and,  if  a  collection  of  pus  is  found,  evacuate  it.  Put  in  a  large  size  rubber  drain- 
age tube  and  pack  the  pelvis  lightly  with  gauze,  letting  the  ends  extend  out  into 
the  vagina  (Figs.  642,  643).  Washed  iodoform  gauze  has  been  recommended 
for  this  intraperitoneal  packing,  but  several  instances  of  iodoform  poisoning  from 
absorption  have  been  reported.  It  is  safer  to  use  plain  gauze  wrung  out  of  a 
weak  bichloride  solution.     The  principal  effect  desired  is  drainage  and  this  is 


TREATMENT    OF    ACUTE   PELVIC   INFLAMMATION 


823 


accomplished  by  the  rubber  tube.  The  gauze  packed  in  the  wound  about  the  tube 
checks  the  bleeding,  and  preserves  a  good-sized  cavity  about  the  tube,  and  thus 
drains  the  entire  pelvis  instead  of  a  small  sinus,  which  might  be  all  that  would 
remain  were  the  structures  allowed  to  collapse  about  the  tube  immediately  after 
its  introduction.  Gauze  is  then  placed  in  the  vagina  and  a  large  dressing  applied 
over  the  vulva,  and  the  patient  put  to  bed.  The  gauze  in  the  vagina  may  be 
removed  in  twenty-four  hours,  the  vagina  cleansed,  and  fresh  gauze  inserted  or 
douches  given,  as  preferred.  The  gauze  in  the  pelvis  should  be  left  in  place  from 
two  to  four  days,  providing  there  is  good  drainage  during  that  time.  When  it 
is  removed,  reintroduce  the  rubber  drainage  tube  to  insure  good  drainage  and 
keep  the  vaginal  wound  from  closing  too  soon. 

Abdominal  Section. — Open  the  abdomen  by  incision  in  the  median  line  and 


Fig.   674.     Vaginal   Section   for  Acute   Pelvic   Inflammation.      A  view   from   above,    showing  the   packing  in 
contact  with  the   inflamed  tubes.      (Kelly — Operative   Gynecology.) 


make  free  drainage  with  a  glass  tube  to  the  depth  of  the  pelvis,  with  or  without 
removal  of  affected  tube  or  tubes,  as  seems  best  in  the  particular  case. 

Of  the  two  methods  of  pelvic  drainage,  the  first  (vaginal  section)  is  the 
preferable  one  in  the  majority  of  cases  of  acute  virulent  pelvic  peritonitis  if 
the  inflammation  is  still  confined  to  the  pelvis.  When  the  general  peritoneal 
cavity  is  not  involved,  vaginal  section  accomplishes  all  the  important  results  that 
can  be  accomplished  by  abdominal  section — the  emptying  of  pus  pockets  and 
free  drainage  of  the  infected  area — and  with  much  less  danger  to  the  patient. 
Of  course,  if  the  infection  has  already  extended  to  the  higher  portions  of  the 
peritoneal  cavity,  there  may  be  pockets  of  septic  fluid  in  the  central  abdomen 
which  can  not  be  evacuated  from  below.    Under  such  circumstances  abdominal 


824  PELA'ic  ixfla:^i:matiox 

operation  is  nsnallv  required,  either  alone  or  in  combination  witli  vag-inal  drain- 
age. In  addition  to  drainage  of  the  infected  peritoneal  cavity  by  vaginal  section 
or  abdominal  section,  or  both,  there  are  certain  other  measures  of  much  import- 
ance in  acute  peritonitis — namely,  stomach  lavage  and  withholding  nourishment 
by  mouth  (to  prevent  injurious  intestinal  peristalsis),  Fowler  posture  (for  drain- 
age) and  the  introduction  of  large  quantities  of  normal  saline  solution  into  the 
sj^stem  (to  strengthen  the  vital  organs  and  aid  elimination). 

The  treatment  of  acute  spreading  peritonitis  of  virulent  type  has  under- 
gone a  radical  change  in  the  last  few  years  and  with  remarkable  reduction  in 
the  mortality.  Formerly  eighty  to  ninety  per  cent  of  these  patients  were  lost. 
Now  eighty  to  ninety  per  cent  are  saved.  This  splendid  result  has  been  obtained 
hy  a  more  intelligent  aiding  of  nature  in  the  limitation*  of  the  infective  process 
and  in  the  elimination  of  the  infective  material.  In  order  to  bring  out  the 
essential  features  in  handling  these  cases  of  general  peritonitis,  or  of  local  peri- 
tonitis threatening  to  become  -general,  it  is  necessary  to  say  a  few  words  in  re- 
gard to  Nature 's  efforts  at  caring  for  them.  The  process  is  best  studied  where 
a  quantity  of  infective  material  is  liberated  suddenly  in  the  peritoneal  ca^dty, 
the  best  examples  of  which  are  seen  in  perforations  of  the  intestinal  tract.  The 
most  common  of  these  is  perforation  of  the  appendix.  Hence,  the  great  advance 
in  the  treatment  of  peritonitis  of  virulent  type  has  been  made  largely  from  the 
study  and  treatment  of  cases  of  perforative  appendicitis.  In  this  study  it  has 
been  established  that,  in  Nature 's  attempt  to  protect  the  system  from  the  infective 
material,  there  are  three  important  factors,  as  follows:  a.  A  wall  of  exudate 
which  surrounds  the  infective  material,  binding  together  the  adjacent  surfaces, 
and  opposing  an  organic  barrier  to  the  spread  of  the  infection,  b.  Immobilization 
of  the  intestinal  coils,  which  prevents  mechanical  spread  of  the  infectious  mate- 
rial, such  as  would  necessarily  take  place  in  the  presence  of  normal  intestinal 
peristalsis.  This  immobilization  of  the  intestinal  coils  is  formed  in  part 
mechanically  by  the  adhesions  forming  the  wall  of  limiting  exudate  and  in  part 
physiologically  by  the  anorexia,  which  causes  very  little  food  to  be  taken,  and 
by  the  vomiting,  which  rejects  a  large  part  of  that  which  is  taken,  c.  Elimina- 
tion— first  of  the  toxins  through  the  kidneys  and  other  eliminative  organs,  and, 
second,  of  the  infectious  material  itself  through  an  opening  to  the  external  sur- 
face of  the  body  or  into  some  hollow  organ. 

Such  in  brief  is  Nature 's  method  of  handling  these  cases.  The  results  vary 
with  the  virulence  of  the  infection,  the  vital  resistance  of  the  individual,  and  the 

*This  limitation  of  the  infective  process  is  effected  by  the  inflammatory  infiltration  and  exudate  and 
adhesions.  These  features  are  protective  and  constitute  Nature's  method  of  combating  the  spread  of  the 
infection.  The  protective  features  of  inflammation  have  been  strongly  emphasized  in  recent  years  by  a 
number  of  writers,  particularly  by  Channing  W,  Barrett,  who  states  in  a  recent  article:  "Inflamma- 
tion is  not  the  fire,  it  is  the  fire  department;  it  is  not  the  epidemic,  it  is  the  health  department;  it  is  not 
the  army  of  invasion,  it  is  the  army  of  defense."  However,  in  combating  the  old  idea  that  inflammation 
was.  wholly  a  destructive  process,  there  is  no  reason  to  go  to  the  other  extreme  and  trv-  to  label  it  as  a 
wholly  constructive  or  protective  process.  Peritonitis  (or  inflammation  in  any  other  situation)  is  a  com,- 
plex  condition,  and  any  complete  conception  of  it  must  include  both  the  invading  organisms  and  the 
resisting  forces.  The  term  "peritonitis"'  is  used,  and  it  seems  rightly  used,  by  ciinicinns  to  designate  tne 
conflict  betweei!  theso  opposing  forces  and  the  usual  results  thereof.  To  use  the  sim.ile  of  the  writer 
above  quoted:  Inflammation  is  not  the  army  of  invasion,  neither  is  it  the  army  of  defense — it  is  the 
conflict  between  the  two.  In  one  case  it  is  a  short  sharp  local  fight,  while  in  another  case  it  is  a  prolonged 
conflict  along  a  far-flung  battle  line,  that  may  involve  the  whole  body. 


TEEATMENT    OF    ACUTE    PELVIC    INFLAMMATION  825 

efficiency  of  the  outside  help.  These  are  desperate  cases.  AVith  or  without  out- 
side help,  the  patient's  life  hangs  in  the  balance,  and  every  move  that  is  made 
should  be  made  with  the  idea  of  aiding  Nature  and  not  handicapping  her.  Such 
intelligent  assistance  can  be  given  only  by  a  well-balanced  consideration  of  each 
of  the  three  factors  above  mentioned.  One  or  another  of  these  factors  has  at 
various  times  been  given  undue  prominence  in  the  treatment.  The  old  opium 
treatment  considered  the  immobilization  and  the  exudate,  with  practically  entire 
neglect  of  elimination,  either  general  or  local.  The  later  treatment  by  operation, 
widespread  irrigation  and  mopping  of  peritoneal  surfaces,  and  extensive  drainage, 
was  based  upon  an  exaggerated  idea  of  the  importance  of  elimination  and  an 
erroneous  idea  as  to  how  to  best  secure  the  really  necessary  elimination.  This 
method,  which  was  practiced  generally  a  few  years  ago,  took  almost  no  account  of 
any  factor  save  drainage. 

In  the  present  method  of  treating  such  spreading  peritonitis  the  wall  of 
exudate  is  preserved  as  far  as  possible  by  employing  simple  drainage  without 
irrigation  or  extensive  exploration,  or  any  other  manipulation,  except  that  nec- 
essary to  give  exit  to  the  infected  material  and  perhaps  remove  a  sloughing 
structure  or  close  an  opening  into  the  intestinal  tract.  The  immobilizatioii  of 
the  adjacent  intestinal  coils  is  favored  by  leaving  the  adhesions  and  by  quieting 
intestinal  peristalsis  through  withholding  all  food  for  a  few  days  and  through 
stomach  ^vashings.  Elimination  is  secured  through  simple  drainage  of  the 
infected  site  and,  when  needed,  of  the  pelvic  peritoneal  pouch,  aided  by  the 
half -sitting  posture  (Fowler's  posture)  and  the  free  use  of  normal  saline  solu- 
tion, particularly  by  slow  continuous  rectal  absorption  (proctoclysis). 

This  combination  treatment  has  reduced  the  mortality  of  acute  general  peri- 
tonitis from  80  to  90  per  cent  to  10  per  cent,  and  even  below.  This  remarkable 
result  is  well  established  and  unquestioned.  However,  there  is  considerable 
difference  of  opinion  as  to  the  relative  importance  of  different  factors  in  the 
treatment.  J.  B.  Murphy  was  the  first  to  arrest  the  attention  of  the  profession 
generally,  and  focus  it  on  this  subject,  by  the  report  in  1905  of  a  series  of  29 
cases  of  acute  general  peritonitis  with  28  recoveries.  Murphy  laid  stress  on  three 
factors — viz.,  simple  drainage  (without  irrigation  or  other  extensive  intraperi- 
toneal disturbance),  the  Fowler  posture  and  protoclysis.  A  later  report  of  his 
experience  (Surgery,  Gynecology  and  Obstetrics,  Feb.,  1910)  gives  58  cases  with 
56  recoveries.  Other  operators  have  secured  nearly  as  good  results  by  this 
treatment,  so  that  it  is  now  very  generally  employed  Avith  the  saving  of  many 
patients.  A.  J.  Ochsner  has  rendered  valuable  service  by  emphasizing  the  neces- 
sity of  intestinal  mobilization  by  withholding  all  food  and  washing  out  the 
stomach.  This  is  important  both  before  operation  and  after  operation  until  the 
process  is  well  localized.  Ochsner  laid  special  emphasis  on  its  use  before  opera- 
tion and  in  certain  carefully  selected  cases,  instead  of  operation  during  the 
acute  stage.  This  last  recommendation,  of  using  it  to  the  exclusion  of  operation 
in  certain  desperate  cases,  is  a  questionable  one  at  present.     "When  this  treat- 


826  pel^t;c  ixflammatiox 

ment  was  first  proposed  as  a  substitute  for  immediate  operation  in  tlie  care- 
fully selected  cases  belonging  to  that  fatal  class  generally  recognized  as  "too 
late  for  early  operation  and  too  early  for  late  operation."  it  undoubtedly  saved 
many  patients,  for  it  was  opposed  to  tlie  extensive  operation  and  general  irriga- 
tion treatment  then  in  use,  which  gave  a  mortality  of  80  to  90  per  cent.  By 
absolute  rest  of  the  stomach  and  upper  bowel,  secured  by  painstaking  attention 
to  detail,  Ochsner  was  able  to  tide  the  patients  over  the  critical  period  and 
operate  later  with  a  reduction  of  the  mortality  to  one-fourth  what  it  Avas  for- 
u^erly — i.  e..  to  the  neighborhood  of  20  per  cent.  "With  the  substitution  of  simple 
drainage,  however,  for  extensive  operation  in  these  cases,  the  serious  objections 
to  operation  (shock  and  mechanical  spread  of  the  infection)  have  practically  dis- 
appeared even  in  the  most  desperate  cases.  AYlien  the  patient  is  so  weak  that 
general  anesthesia  is  not  advisable,  the  simple  drainage  may  be  made  under  local 
anesthesia  and  the  exit  of  infected  material  through  this  vent  may  turn  the  tide 
of  battle  to  the  saving  of  the  patient.  That  this  is  true  is  shown  conclusively,  it 
seems,  by  the  fact  that  Murphy,  employing  drainage  associated  with  other  less 
important  features,  was  able  to  save  56  out  of  a  series  of  58  cases — reduction  of 
the  mortality  to  less  than  4  per  cent. 

Associated  with  drainage,  stomach  washing  and  intestinal  rest  are  im- 
portant features,  both  before  and  after  operation.     In  fact,  some  insist  that 
the  splendid  results  which  attend  the  "Murphy  treatment"  are  due,  aside 
from  drainage,  almost  entirely  to  the  stomach  and  intestinal  rest  so  strongly 
emphasized  by  Ochsner.     In  a  recent  article,  G.  S.  Brown,  in  support  of  the 
contention,  reports  a  series  of  17  cases  of  diffuse  peritonitis  with  14  recov- 
eries, in  which  the  treatment  employed  was  drainage  by  operation  combined 
with  the  antiperistaltic  regime  of  Ochsner,  "vrithout  the  use  of  the  Murphy- 
Fowler  features."     It  is  difficult  to  decide  certainly  as  to  the  relative  im- 
portance of  each  of  tlie  factors  which  enter  into  the  present  successful  treat- 
ment of  extensive  peritonitis.     There  are  several  reasons  for  this.     There  are 
certain  essential  technical  details   about   some   of  the  factors  that   are  not 
always   fully   comprehended   and   carried    out.   hence    confidence   may   be   lost 
■  in  one  or  another  feature  of  the  treatment  simply  through  the  inefficiency  of 
the  one  who  employs  it.     Again,  physicians  differ  much  as  to  the  cases  they 
classify  under  "acute  diffuse  peritonitis,"  thus  causing  a  marked  difference 
in   the  mortality   records.      Still    again,   the   combination  method   generally 
employed,  while  contributing  to  splendid  results,  contributes  also  to  uncer- 
tainty as  to  the  relative  importance   of  the   various  features.     This   uncer- 
tainty is  mentioned  not  to  discourage  the  use  of  the  combination  treatment, 
but  simply  to  call  attention  to  the  fact  that  there  is  probably  good  in  each  of 
the  features  and  that  it  is  not  wise  to  make  positive  statements  as  to  the  ex- 
clusive sufficiency  of  this  or  that  feature  until  we  have  acquired  more  definite 
knowledge  through  further  experience. 

The   combination  treatment   for   acute   spreading  peritonitis   considered 
best  is,  in  detail,  as  follows: 


TREATMENT    OF    ACUTE    PELVIC    INFLAMMATION  827 

a.  Withhold  all  Food  and  Cathartics  by  Mouth  and  Empty  the  Stomach 
"With  a  Stomach-tube.  As  soon  as  an  acute  spreading  peritonitis  is  recog- 
nized, arrangements  slionld  at  once  be  made  for  a  drainage  operation.  The 
sooner  the  infecting  material  is  given  an  external  exit,  the  better  will  be  the 
patient's  chance  for  recovery.  While  preparing  for  the  operation,  however, 
and  also  subsequent  to  operation,  this  antiperistaltic  treatment  is  indicated. 
There  are  certain  details  that  must  be  carried  out  to  the  letter  to  secure 
the  best  results.  No  food  of  any  kind  is  to  be  given  by  mouth,  not  even  a 
teaspoonful  of  liquid  nourishment.  The  least  nourishment  taken  into  the 
stomach  and  passing  into  the  intestine  will  excite  intestinal  peristalsis  and 
defeat  the  purpose  of  the  treatment.  Also,  the  food  already  in  the  stomach 
will  excite  peristalsis  unless  removed.  Very  often  considerable  has  been 
removed  by  vomiting,  but  vomiting  is  not  to  be  depended  upon.  Though 
the  patient  has  vomited  several  times,  still  there  may  be  enough  food  rem- 
nants remaining  to  pass  into  the  intestine  and  excite  it  to  action.  In  fact 
the  persistence  of  vomiting  indicates  the  presence  of  some  irritating  ma- 
terial in  the  stomach.  Consequently,  the  stomach-tube  should  be  used  to  in- 
sure thorough  emptying  of  the  stomach  in  every  case,  except  where  there  is 
some  special  contraindication  to  its  use  (ulcer  of  stoinach,  carcinoma,  child 
too  young,  etc.) 

The  gastric  lavage  may  be  simplified  and  made  less  disagreeable  by  at- 
tention to  details.  Turn  the  patient  well  over  on  the  side,  preferably  the 
side  in  which  the  inflammatory  process  is  located.  Spray  the  pharynx  with 
a  four  per  cent  solution  of  cocaine,  spray  it  three  or  four  times  in  the  course 
of  five  minutes,  directing  the  patient  to  hold  the  solution  in  the  pharynx  for 
a  few  seconds  and  then  expectorate  it.  The  stomach-tube  should  be  of  good 
size,  with  an  opening  at  the  side  as  well  as  at  the  end.  Cool  it  in  ice  water 
and  introduce  it  without  special  lubrication — simply  Avet  with  the  ice  water. 
Direct  the  patient  to  assist  the  passage  of  the  tube  along  the  esophagus  by 
swallowing  repeatedly.  Gastric  lavage  has  come  into  such  general  use  in 
the  treatment  of  postoperative  gastric  dilatation  and  other  conditions,  and 
is  so  necessary,  that  a  physician  having  anything  to  do  with  an  abdominal 
case  should  know  how  to  introduce  the  stomach-tube  without  disturbing  the 
patient  overmuch.  When  the  tube  has  reached  the  stomach,  siphon  out  the 
contents.  Then  introduce  warm  normal  saline  solution  and  siphon  it  out 
repeatedly  until  it  returns  clear.  Use  a  pint  and  more  if  necessary,  and  at 
the  end  empty  the  stomach  as  nearly  as  possible. 

This  gastric  lavage  makes  the  patient  more  comfortable.  It  gives  the 
stomach  rest  from  irritating  decomposing  material,  diminishes  the  peristalsis, 
diminishes  the  distention,  and  stops  the  vomiting,  which  in  itself  does  harm 
jjy  disturbing  the  limiting  adhesions.  The  one  stomach  washing  may  be  all 
that  is  needed.  If  the  vomiting  recurs,  however,  lavage  is  again  indicated, 
for  it  means  usually  that  reverse  peristalsis  has  brought  material  from  the 
upper  intestine  into  the  stomach,  and  this  should  be  removed  by  the  tube 


828  PELVIC   INFLAMMATION 

as  was  the  first.  In  Nature's  method  of  localizing  the  infection,  inhibition  of 
peristalsis  in  adjacent  intestinal  coils  (temporary  intestinal  paralysis)  is  an 
important  factor.  If  there  is  food  in  the  upper  intestine,  it  excites  peristalsis. 
Now,  this  normal  peristalsis  and  onward  progress  being  interfered  with  by 
the  immobilization  of  certain  intestinal  coils,  there  is  reverse  peristalsis, 
which  carries  the  irritating  material  back  into  the  stomach,  where  it  is 
partially  thrown  off  by  vomiting.  The  continued  administration  of  food,  and 
especially  of  cathartics,  aggravates  the  peristalsis  and  reverse  peristalsis, 
adding  much  to  the  patient's  danger  and  discomfort.  Two  or  three  extra 
stomach  washings  at  intervals  of  several  hours  may  be  necessary  before  com- 
plete rest  of  the  stomach  and  bowel  is  secured.  This  complete  emptying  of 
the  stomach  and  upper  bowel  has  a  very  decided  effect  within  twelve  to 
twenty-four  hours.  There  is  cessation  of  the  vomiting  and  diminution  of 
the  nausea,  distention,  pain  and  fever.  The  pulse  and  respiration  improve, 
and  the  discomfort  and  threatening  symptoms  disappear  to  a  large  extent. 
Ochsner  remarks,  ''Usually  the  improvement  is  so  rapid  that  one  is  tempted 
to  spoil  everything  by  giving  nourishment  by  mouth,  because  the  patient's 
condition  does  not  seem  serious  enough  to  warrant  such  severe  deprivation 
measures."  This  treatment  is  to  be  used  while  arrangements  are  being  made 
for  operation  and  it  is  to  be  used  also  after  operation,  along  with  the 
Fowler  posture,  proctoclysis  and  rectal  nourishment  until  the  inflammatory 
process  is  well  localized  and  stomach  feeding  may  be  safely  resumed. 

b.  Drainag-e  of  the  Infected  Area,  With  the  Least  Possible  Intraperi- 
toneal Disturbance.  This  should  be  carried  out  as  soon  as  possible.  There 
should  be  no  irrigation  and  no  breaking  of  adhesions,  beyond  that  absolutely 
necessary  to  drain  the  pus  pocket  or  pockets  and,  in  certain  exceptional 
cases,  to  remove  sloughing  tissue  or  close  a  hole  in  the  intestinal  wall.  The 
anesthesia  should  be  of  the  shortest  possible  duration,  in  order  to  diminish 
the  further  burden  on  the  already  overburdened  eliminative  organs.  In  some 
cases  the  drainage  operation  can  be  carried  out  largely  or  wholly  under 
local  anesthesia,  aided  by  a  dose  of  morphine  given  about  half  an  hour 
before.  As  a  rule  tube  drainage  in  some  form  should  be  employed,  with  or 
without  gauze,  as  preferred.  If  the  pelvic  peritoneal  cul-de-sac  is  to  be 
drained  through  an  abdominal  incision,  the  glass  tube  is  best.  In  other  situa- 
tions rubber  tubing  is  preferable.  It  may  be  split  spirally  or  longitudinally, 
or  may  have  holes  cut  in  the  sides.  If  the  drainage  is  made  per  vaginam, 
the  drainage  tube  should  have  a  cross-piece  (Fig.  670)  to  prevent  it  slipping 
out,  for  in  this  situation  the  tube  must  remain  a  long  time,  as  previously  ex- 
plained. In  cases  where  there  are  several  pockets  which  can  not  be  drained 
satisfactorily  through  one  tube,  it  may  be  necessary  to  put  in  Iavo  or  more 
tubes,  bringing  them  out  through  the  same  opening  in  the  abdominal  Avail  or 
through  separate  openings. 

c.  The  Fowler  Posture.  Immediately  following  the  drainage  operation 
the  head  of  the  bed  should  be  raised  two  feet.     This  causes  all  fluid  in  the 


TREATMENT    OF    ACUTE    PELVIC    INFLAMMATION 


829 


peritoneal  eavitv  to  gravitate  to  the  pelvis,  vliere  it  escapes  throngli  the 
drainage  tube.  As  soon  as  the  patient  is  strong  enough — that  is,  Avithin  a  day 
or  two — this  drainage  may  be  more  comfortably  and  efficiently  maintained 
by  the  regular  Fovler  posture — half  sitting  posture. 

d.  Proctoclysis.  The  introduction  of  normal  saline  solution  into  the 
system  gives  important  aid  to  the  heart  and  kidneys,  and  facilitates  the 
elimination  of  septic  material.    If  the  patient  is  very  weak  immediately  after 


Fig.  675. 


576. 


Fig.  675.  Simple  apparatus  for  proctoclysis,  a,  irrigator  can;  h,  rubber  tube  with  clamp,  c,  which 
permits  accurate  adjustment  of  flow,  controlled  by  the  rate  of  drops  passing  through  glass  bulb,  d;  at  e  the 
tube  h  is  attached,  which  permits  escape  of  flatus;  g,  catheter  introduced  into  rectum;  i,  bent  glass  tube; 
j,  electric  light  bulb,  during  use  of  apparatus,  dipped  into  fluid  in  can,  a,  to  keep  solution  warm. 

Fig.   676.      Same   apparatus   without   attachments   to   control   flow    and   to   permit   escape    of   flatus. 

the  drainage  operation,  one  or  two  pints  of  the  solution  may  be  given  sub- 
cutaneously.  At  the  same  time  the  giving  of  the  solution  by  the  rectum 
should  be  begun,  to  be  continued  for  several  days.  It  is  best  given  by  slow 
continuous  absorption.  To  secure  this,  certain  essentials  must  be  observed,  as 
follows:  (a)  the  fluid,  normal  saline  solution  or  tap  water,  must  be  main- 
tained at  a  temperature  of  about  100°  F.,  (b)  it  must  flow  into  the  rectum 
slowly,  drop  by  drop   (about  one  and  a  half  pints  per  hour),  and   (c)  there 


830  pel^t;c  ixfla^imatiox 

iiiiist  be  110  obstruction  or  eoiistrietion  in  tlie  tube  that  would  interfere  with 
the  free  regurgitation  of  fluid  or  gas  from  the  rectum.  The  apparatus^ 
whether  simple  or  elaborate,  must  conform  to  these  essentials.  The  suc- 
cess of  the  method  depends  upon  accuracy  in  its  application. 

Proctoclysis  is  started  as  soon  as  patient  is  returned  to  bed  after  opera- 
tion. Irrigator  can  (a)  (Fig.  675)  is  filled  with  normal  saline  solution  or 
plain  tap  water  of  100°  F.  and  the  electric  light  bulb  (j)  dipped  into  the 
fluid  to  maintain  the  temperature.  The  irrigator  can  is  suspended  on  the 
usual  irrigator  stand  about  three  feet  above  the  level  of  the  bed.  Screw  (c) 
is  adjusted  until  the  desired  flow  is  obtained,  usually  between  30  to  50  drops 
to  the  minute,  as  is  accurately  ascertained  in  the  glass  bulb  (d).  Then  the 
catheter  (g)  is  carefully  inserted  deep  into  the  rectum.  Flatus  may  escape 
through  tube  (//)  attached  to  edge  of  irrigator  by  means  of  the  glass  tube 
(i).  If  patient  is  unable  to  retain  the  fluid,  the  flow  is  either  stopped  tem- 
porarily or,  preferably,  screw  (c)  set  closer  so  that  the  flow  is  reduced  ta 
30  drops  or  even  less  to  the  minute. 

e.  Nourishment  Per  Rectum.  Give  an  ounce  of  some  one  of  the  reliable 
predigested  foods  to  three  ounces  of  normal  saline  solution  every  four  hours. 
This  may  be  given  by  the  drop  method  instead  of  like  amount  of  plain  nor- 
mal saline  solution,  or  it  may  be  given  as  an  ordinary  low  enema  if  it  is  de- 
sired to  remove  the  tube  for  a  time.  Xo  large  enemas  are  to  be  used  during' 
the  acute  stage,  as  they  might  excite  intestinal  peristalsis.  After  the  process 
is  well  localized  and  the  threatening  symptoms  have  disappeared,  stomach 
feeding  may  be  gradually  resumed. 

f.  Serum  Therapy — Vaccine.  There  are  various  measures  that  tend  to 
increase  the  patient's  resistance,  and  these  aid  in  checking  the  progress  of 
the  infection.  In  most  eases  the  treatment  already  mentiond  will  suffice  to 
effect  a  cure.  In  exceptional  cases,  however,  the  uifeetion  still  continues 
to  spread  and  threaten  the  patient's  life.  This  is  seen  not  infrequently  in 
certain  puerperal  infections — puerperal  peritonitis,  puerperal  cellulitis  and 
particularly  in  puerperal  septic  thrombo-phlebitis.  All  surgical  indications 
having  been  promptly  met,  we  are  not  yet  through,  but  must  use  eveiy 
possible  means  to  increase  the  patient's  vital  resistance.  There  is  now  a 
severe  conflict  and  in  some  cases  a  prolonged  conflict  between  the  invading* 
bacteria  and  the  defending  forces  of  the  body.  Measures  that  increase  leu- 
cocytosis,  and  strengthen  the  other  resisting  forces,  aid  Nature  in  the  fight 
and  may  decide  the  issue  favorably.  Antistreptococcic  serum  has  seemed  to 
aid  materially  in  some  cases.  In  spite  of  the  fact  that  in  many  cases  it  has 
no  effect  and  that  a  number  of  physicians  have  lost  faith  in  it,  the  author 
does  not  feel  ready  to  give  it  up.  AVhen  having  a  considerable  experience 
in  such  cases,  we  are  necessarily  guided  by  our  own  observations  and  opin- 
ions to  a  large  extent.  The  author  has  used  the  antistreptococcic  serum  many 
times  with  no  effect,  but,  on  the  other  hand,  has  repeatedly  noted  marked  im- 
provement apparently  due  to  it — that  is,  due  to  nothing  else  so  far  as  could 


TREATMENT   OF    ACUTE   PELVIC    INFLAMMATION  831 

be  seen.  These  are  desperate  cases,  that  have  got  beyond  the  reach  of 
direct  measures,  and  the  control  of  the  situation  has  slipped  out  of  our  grasp. 
This  is  not  an  occasion  for  theorizing.  Anything  that  offers  a  substantial 
chance  of  improvement  and  will  do  no  harm  should  be  used.  Consequently, 
until  this  subject  is  more  definitely  cleared  up,  the  author  shall  continue  to 
use  the  polyvalent  antistreptococcus  serum  in  doses  of  20  c.c,  one  dose  every 
■  24  hours,  until  three  doses  are  given.  If  no  effect,  no  more  is  used.  If  a 
favorable  effect,  the  administration  of  serum  is  continued  at  intervals  as 
indicated  by  the  temperature. 

Vaccine  therapy,  as  far  as  developed,  has  been  effective  principally  in 
chronic  infections.  A  few  apparently  favorable  results  have  been  reported 
in  the  acute  infections  under  consideration,  but  these  are  uncertain,  and  its 
use  here  is  wholly  experimental  as  yet.  In  an  infection  resisting  other  meas- 
ures it  is  well  to  try  this.  Autogenous  vaccine  is  the  preferable  form,  but,, 
if  this  can  not  be  made,  then  use  stock  vaccine — streptococcic,  staphylo- 
coccic or  gonococcic,  as  indicated  by  the  clinical  and  bacteriologic  evidences 
in  the  ease. 

Employ  also  the  various  other  measures  used  to  increase  or  conserve  the 
patient's  vital  .resistance — namely,  concentrated  nourishment,  stimulants^ 
laxatives,  sedatives,  etc.,  according  to  usual  indications. 

6.  Septic  Thrombo-phlebitis.  The  nature  and  ramifications  of  this  proc- 
ess have  been  indicated  on  pages  808  to  810,  and  as  long  as  the  septic  process, 
is  confined  to  accessible  veins  there  is  still  a  chance  to  limit  it  artificially  by 
ligation  of  the  affected  veins  proximal  to  the  infection.  This  subject  is 
still  in  the  experimental  stage.  A  number  of  patients  have  been  operated 
on.  Some  good  has  been  accomplished,  and  there  is  promise  of  more  for  the 
future.  Whenever  a  puerperal  septic  patient  has  repeated  chills  and  high 
fever,  persisting  after  the  uterus  has  been  cleared  out,  and  with  no  general 
lesion  nor  palpable  local  lesion  to  account  for  these  manifestations,  the  ques- 
tion of  septic  thrombosis  and  possible  operation  should  be  considered.  In 
these  cases  it  is  important  also  to  employ  the  measures  mentioned  above  for 
increasing  the  patient's  resisting  power. 

7.  In  a  case  of  apparent  pelvic  inflammation  where  the  diagnosis  is 
doubtful,  operation  may  be  indicated  on  account  of  the  probability  or  possi- 
bility of  some  other  condition,  which  would  require  operation  at  once — such, 
for  example,  as  tubal  pregnancy  or  appendicitis  or  a  suppurating  tumor.  As 
a  rule,  in  any  of  these  conditions,  if  the  symptoms  are  severe,  immediate 
operation  is  necessary.  Consequently,  in  doubtful  cases,  where  these  con- 
ditions can  not  be  excluded,  if  the  patient  is  growing  worse,  operation  at 
once  is  indicated. 

Prognosis 

What  ultimate  results  can  be  expected  in  these  cases  of  acute  pelvie 
inflammation?    What  is  the  after-history  of  these  patients? 


832  PELVIC   INFLAMMATION 

For  the  purpose  of  prognosis  it  is  convenient  to  divide  the  cases  into 
two  classes— (A)  those  not  requiring  operation  and  (B)  those  that  do  require 
operation. 

A.  If  the  patient  can  be  tided  over  the  most  acute  stage  of  the  attack 
without  operation    one  of  the  following  terminations  will  take  place. 

1.  Complete  Recovery.  In  these  cases  the  germs  are  destroyed,  the 
plastic  and  serous  exudate  is  absorbed,  the  pains  disappear,  the  patient  comes 
to  feel  well  and  functional  activity  is  restored.  That  such  a  termination  does 
take  place  even  in  some  severe  cases  is  proved  conclusively  by  the  cases  of 
salpingitis  and  pelvic  peritonitis,  from  infection  following  labor  or  abor- 
tion, in  which  the  patients  eventually  recover  and  have  good  health  and  bear 
children.  No  doubt  a  few  adhesions  remain,  but  not  enough  to  cause  pain 
nor  to  interfere  with  function.  This  very  desirable  termination  is  much 
more  liable  to  take  place  in  ordinary  septic  inflammation  than  in  gonorrheal 
inflammation.  In  gonorrheal  inflammation  the  immediate  danger  to  life  is  not 
so  marked  as  in  other  forms  of  pelvic  infection,  but  the  ultimate  danger  to 
health  in  the  cases  that  survive  is  much  more  marked.  In  a  much  larger  pro- 
portion of  the  gonorrheal  cases  the  acute  trouble  is  followed  by  serious  chronic 
pelvic  inflammation,  causing  sterility  and  persistent  invalidism. 

2.  Partial  Recovery.  Functional  activity  is  not  restored.  The  exudate 
is  largely  absorbed  and  the  pain  disappears,  and  the  patient  feels  well.  But 
she  is  sterile — the  sterility  being  due  usually  to  remaining  inflltration  and 

•  adhesions  that  occlude  the  tubes  and  otherwise  damage  them. 

3.  Chronic  Pelvic  Inflammation.  A  large  percentage  of  the  cases  of 
acute  pelvic  inflammation  terminate  in  chronic  pelvic  inflammation.  There 
may  be  foimd  a  pelvic  abscess,  which  requires  opening  and  drainage  by  way 
of  the  vagina  or  removal  by  abdominal  section.  More  frequently,  however, 
there  is  a  mass  of  exudate  without  a  distinct  collection  of  pus,  but  with  a 
focus  of  chronic  inflammation  which  acts  as  a  source  of  constant  irritation, 
causing  pain  on  exertion  and  marked  menstrual  disturbance,  and  giving  rise 
to  frequent  attacks  of  pelvic  peritonitis. 

4.  Death  from  Persistent  Sepsis.  The  patient  survives  the  acute  symp- 
toms at  the  beginning  of  the  attack,  but  still  there  continues  septic  absorp- 
tion or  there  develops  general  pyemia.  There  is  irregular  fever,  with  re- 
peated chills  if  pyemia  is  present,  emaciation,  increasing  weakness  and  finally 
death,  two  weeks  to  two  months  from  the  outset  of  the  trouble. 

This  result  is  much  more  liable  to  take  place  where  there  is  serious  dis- 
ease elsewhere — for  example,  in  the  kidneys  or  heart,  or  lungs  or.  gastro- 
intestinal tract. 

B.  If  the  inflammation  is  so  severe  that  the  patient's  life  is  threatened 
and  immediate  operation  is  required  and  carried  out,  the  following  are  the 
terminations : 

1.  Complete  Recovery.     Of  the   operative  eases  that  survive  the   acute 


CHRONIC   PELVIC   INFLAMMATION  833 

attack  a  large  proportion  is  permanently  cured.     The  patient's  health  may 
be  fully  restored  and  she  is  again  capable  of  child-bearing. 

2.  Partial  Recovery.  The  exudate  is  absorbed,  the  pain  disappears  and 
the  patient  has  good  health — but  she  remains  sterile. 

3.  Chronic  Pelvic  Inflammation.  In  the  septic  cases  following  labor  or 
miscarriage  the  troublesome  postoperative  lesions  are  usually  adhesions 
and  plastic  exudate.  In  the  gonorrheal  cases  the  other  tube  is  very  liable 
to  become  inflamed  and  pass  through  the  same  process  as  the  one  removed. 
In  vaginal  drainage  cases,  v^^hether  septic  or  gonorrheal,  the  drainage  tract 
may  close  too  soon,  alloAving  the  abscess  to  reform,  or  another  focus  may  go 
on  to  abscess  formation. 

4.  Death  in  Spite  of  Operation.  In  many  of  these  cases  the  inflammation 
is  so  virulent  that  no  operation  will  stop  its  progress.  On  the  other  hand, 
in  some  of  the  most  threatening  cases  the  patient's  life  is  apparently  saved  by 
operation. 

The  prognosis  in  regard  to  pregnancy  in  patients  who  apparently  re- 
cover from  acute  pelvic  inflammation,  with  or  without  operation,  is  as  fol- 
lows : 

1.  If  the  previous  inflammation  was  of  the  ordinary  septic  variety,  there 
is  a  fairly  good  chance  of  pregnancy  later.  Of  course,  such  a  patient  is  not 
so  liable  to  become  pregnant  as  a  perfectly  healthy  woman,  and  if  she  does 
become  pregnant  she  is  more  liable  to  miscarry.  However,  many  women 
Avho  have  passed  through  one  or  more  attacks  of  severe  puerperal  sepsis,  with 
involvement  of  tubes  and  peritoneum,  recover  apparently  completely  and 
continue  to  bear  children  as  though  there  had  been  no  trouble. 

2.  If  the  previous  inflammation  was  gonorrheal,  involving  the  tubes  and 
peritoneum,  there  is  almost  certain  to  be  sterility.  This  is  one  of  the  causes 
of  sterility  in  prostitutes,  and  it  is  also  a  cause  of  many  childless  homes. 
The  husband,  having  previously  had  gonorrhea  and  supposing  himself  well, 
married  and  unknowingly  carried  infection  to  his  wife  and  thus  destroyed 
her  chance  of  becoming  a  mother.  Fortunately,  sterility  does  not  invariably 
follow  gonorrheal  salpingitis,  some  patients  recovering  sufficiently  to  be- 
come pregnant. 

CHRONIC  PELVIC  INFLAMMATION 

The  inflammatory  process  may  be  situated  principally  in  the  Fallopian 
tubes  and  pelvic  peritoneum,  or  in  the  pelvic  connective  tissue,  or  in  the 
ovaries. 

In  chronic  pelvic  inflammation  the  separate  forms  of  the  disease  are 
more  distinct  than  in  the  acute  variety — that  is,  the  cases  may  be  divided 
into  distinct  groups,  representing  the  different  localizations  of  the  inflam- 
matory process  and  differing  considerably  in  etiology,  pathology  and  symp- 
tomatology.    The  cases  may  be  divided  into  three  groups — (A)   chronic  sal- 


834  pel^t:c  ixflammatiox 

piugitis  lAvith  complicating-  ooplioritis  and  chronic  pelvic  peritonitis,  caus- 
ing peritoneal  exudate  and  adhesions),  (B)  chronic  pelvic  cellulitis  f para- 
metritis), and  (C)   chronic  oophoritis  (cystic  ovary). 

(A)  CHEOXIC  SALPINGITIS 

Etiology 

Chronic  salpingitis  foUoAvs  acute  salpingitis.  In  practically  every  case 
of  genital  origin  there  has  been  endometritis  due  to  infection  follo^ving 
labor,  or  miscarriage,  or  gonorrhea.  Chronic  pyosalpinx  alone  (without  in- 
volvement of  the  parametrium )  is  nearly  ahvays  due  to  the  gonococcus,  recog- 
nized or  unrecognized — even  in  the  cases  in  vdiich  the  infection  dates  from 
a  labor  or  miscarriage.  The  detailed  proofs  of  this  fact  and  the  apparent  ex- 
ceptions will  be  discussed  later,  along  with  their  bearing  on  the  operative 
treatment  of  chronic  inflammatory  masses  in  the  pelvis  (see  pages  851  to  867). 
From  the  endometrium  the  inflammation  extends  to  the  tube,  causing  first 
acute  salpingitis  and  later  chronic  salpingitis. 

The  normal  tubal  lumen  is  practically  filled  with  the  folds  of  the  normal 
mucous  membrane  as  seen  in  Fig.  680.  In  the  inflamed  tube  these  folds  swell 
up.  the  covering  epithelium  becomes  necrotic  and  the  result  is  an  agglutina- 
tion of  many  of  these  folds  (Fig.  679).  In  the  deeper  layers  of  the  mucosa  by 
the  fusing  of  the  ends  of  the  folds  small  cystic  cavities  are  formed.  The 
round  cell  infiltration  is  pronounced  and  extends  into  the  underlying  mus- 
cular layer  of  the  tube  (Fig.  681). 

Pathology 

In  chronic  inflammation  of  the  tube  there  is  found  much  the  same 
variety  of  pathologic  changes  as  has  been  mentioned  under  acute  inflam- 
mation. Howe^'er,  the  serous  exudate  (whether  in  the  cavity  or  in  the  tis- 
sues of  the  tube,  wall)  has  been  largely  absorbed,  and  all  active  infection  is 
confined  to  one  or  more  areas  which  are  Avell  surrounded  hy  plastic  exudate. 
Any  collection  of  pus  is  well  walled  in,  and  in  some  cases  is  sterile  from  long 
standing.  The  adhesions,  which  at  first  were  simply  fibrinous  exudate,  are 
now  organized  and  contain  fibrous  tissue  and  smaU  A'essels.  Some  of  the  ad- 
hesions now  become  stretched  into  long  bands  or  attenuated  cords,  owing  to 
the  constant  movement  of  the  organs.  The  cases  may  be  divided  in  classes 
as  follows: 

1.  Mild  Salpingitis  (Fig.  677).  In  the  cases  of  this  class  the  ends  of  the 
affected  tube  are  occluded  and  the  fimbriae  matted  together  and  distorted, 
and  frequ<^ntly  adherent  to  the  ovary  or  some  other  adjacent  organ.  The 
wall  of  the  tu])e  is  thickened  and  the  cavity  is  empty. 

2.  Salpingitis  with  Exudate  (Fig.  678).    In  the  cases  of  this  class  there 


CHRONIC    SALPINGITIS 


835 


is  a  mass  of  exudate  about  the  tube,  binding  together  the  adjacent  organs, 
Init  th^re  is  no  distinct  collection  of  pus. 

3.  Pyosalpinx  (Figs.  638,  684,  685).  The  occluded  tube  contains  pus. 
There  may  or  may  not  be  extensive  exudate  and  adhesions.  There  is  no  pus 
outside  the  tube. 


Fig.   677.     Mild  Salpingitis  on  the  Left  Side.     Contrast  this  with  the  normal  right  tube.     Notice  the  enlarge- 
ment and  tortuosity  of  the  affected  tube,  and  also  the  distortion  of  the  fimbriae. 


4.  Diffuse  Pelvic  Suppuration  (Fig.  686).  In  the  cases  of  this  class  the 
pus  has  extended  outside  the  tube.  As  the  pus  extends  in  various  directions, 
the  exudate  extends  in  front  of  it,  shutting  it  off  from  the  general  peritoneal 
cavity.     As   in   acute   inflammation,   this   process   may   extend   until   all  the 


836 


PELVIC   INFLAMMATION 


pelvic  organs  are  bound  together  in  an  irregular  mass,  with  pus  lying  in  the 
spaces  between  them. 

5,  Ovarian  Abscess    (Fig.   687).     The  inflammation  may  extend  to  the 
ovary,  forming  an  ovarian  abscess  in  communication  with  a  tubal  abscess 


Fig.  678.  Salpingitis  with  Exudate.  On  left  side  is  indicated  salpingitis  with  a  few  adhesions.  On 
right  side  is  indicated  salpingitis  with  extensive  exudate  and  adhesions.  The  section  indicates  the  relation 
of  the  thickened  tube,  the  ovary,  and  the  surrounding  exudate. 


(Fig.  687,  right  side).     More  rarely  there  is  a  distinct  ovarian  abscess  with- 
out evident  pus  formation  in  the  tube   (Fig.  687,  left  side). 

6.  Hydrosalpinx  (Fig.  688).  The  tube  may  be  much  distended  and  con- 
tains serous  fluid,  but  no  pus.  As  the  result  of  the  pressure  of  the  fluid  within 
the  closed  tube  the  largest  part  of  the  mucous  lining  is  destroyed  (Fig.  689). 


CHRONIC    SALPINGITIS 


837 


Fig.  679.  Chronic  Salpingitis.  Cross  section  o£ 
tube.  Note  the  agglutination  of  mucosal  folds  anJ 
total  disorganization  of  the  tubal  interior. 


Fig.  680.  Cross  section  of  a  normal  tube  to 
contrast  with  Fig.  679.  Notice  the  intricate  system 
of  delicate  mucosal  folds. 


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S  "fi^ 

~ 

w 

'  ,^ 

.  .-'/f5 

i 

*  i  "^ 

- 

'  -  .- 

'■.'      »     "    * 

"■  '  /, 

"  x>  - 

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if''irir^,?-'*  •j,  .  ' '  ■••  '■_ 


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Fig.    681.      Chronic    Salpingitis,    low    power.      The 
mucosal   area   is   shown   at   top    of   photomicrograph. 


Fig.  682.     Chronic    Salpingitis,    higher   power. 


838  PELVIC   INFLAMMATION 

Only  here  and  there  a  preserved  typical  fold  can  b©  seen  (Fig.  690).     There 
may  or  may  not  be  many  adhesions. 

7.  Nodular  Salpingitis  (Fig.  691).    The  wall  of  the  tube  becomes  greatly 
thickened,  the  thickening  being  so  irregular  as  to  give  the  tube  a  distinctly 


Fig.  683.  Pyosalpinx.  Left  tube  distended  with  pus,  but  with  a  -few  adhesions.  Right  tube  dis- 
tended with  pus  and  surrounded  by  extensive  adhesions.  The  section  on  the  right  side  indicates  the  relation 
of  the  distended  tube  to  the  surrounding  structures.  The  sectioned  ovary  is  indicated  dimly  below  and  to 
the  outer  side  of  the  enlarged  tube,  which  has  fallen  behind  and  ^to  the  inner  side  of  it. 

nodular  appearance.     Usually  both  tubes  are  affected,  and  frequently  there 
is  also  chronic  ooi^horitis  of  one  or  both  sides. 

8.  Adhesions  (Fig.  692).  There  is  a  class  of  cases  of  chronic  salpingitis 
in  which  the  tubal  trouble  is  slight  or  has  largely  disappeared,  but  the  re- 
sulting peritoneal  adhesions  are  extensive  and  troublesome,  dislocating  the 


CHRONIC    SALPINGITIS 


839 


Fig.  684.  Section  througli  a  Pyosalpinx,  contrasting  the  fairly  normal  uterine  end  of  the  tube  (to 
the  left)  to  the  excessive  distention  of  its  closed  abdominal  end  (to  right)  by  pus,  hardened  by  preservation 
of  specimen  in  formalin. 


^^f 


Fig.  685.  A  very  large  Pyosalpinx  removed  intact  together  with  the  uterus,  which  has  been  amputated 
supra  vaginally  just  above  the  cervix.  The  specimen  is  shown  from  the  back  and  represents  clearly  the 
tortuous  appearance  of  the  greatly  distended  left  tube. 


840 


PELVIC   INFLAMMATION 


tubes  and  ovaries  and  holding  them  firmly  in  abnormal  positions.  In  such 
cases  all  active  infection  may  have  disappeared,  leaving  only  the  sequelae, 
consisting  of  exudate,  adhesions  and  distortions. 

Symptoms 

The  symptoms  of  which  the  patient  complains  in  chronic  pelvic  inflam- 
mation are  backache  and  pain  in  the  pelvis,  increased  by  walking  or  work- 


4- 


Fig.  686.  Diffuse  Pelvic  Suppuration  from  Pyosalpinx.  The  pus  has  broken  through  the  tube  wall, 
spread  among  the  intestinal  coils  and  gravitated  to  the  cul-de-sac.  A  window,  cut  in  the  distended  tube, 
shows  the  connection  of  the  suppurating  tract  with  the  tubal  cavity. 

ing.  There  is  tenderness  in  the  lower  abdomen,  usually  over  one  or  both  tubes. 
There  are  decided  menstrual  disturbances,  consisting  of  painful  menstruation, 
prolonged  menstruation  and  an  increase  of  all  the  troublesome  symptoms  at 
the  menstrual  periods.  The  patient  complains  of  weakness  and  loss  of  weight, 
and  an  inability  to  stand  walking  or  working  as  she  formerly  did.  Vaginal 
discharge  is  usually  present,  due  to  the  accompanying  endometritis.     There 


CHRONIC    SALPINGITIS 


841 


occur  also  exacerbations,  in  Mhich  the  patient  has  sharp  pain  and  some  fever, 
and  is  sick  in  bed  from  a  few  days  to  several  weeks. 

On  examination  there  is  found  tenderness  in  the  tubal  region  of  one  or 
both  sides  and  in  most  eases  a  mass  in  the  same  region.  If  the  inflammation 
is  slight,  there  may  be  no  mass  of  exudate,  but  simply  a  thickening  of  the 


Fig.  687.  Ovarian  Abscess.  A  window,  cut  in  the  wall  of  the  abscess  on  the  right  side,  shows  that 
it  is  composed  of  a  tubal  portion  and  an  ovarian  portion  (tubo-ovarian  abscess),  with  a  communication  be- 
tween the  two  cavities.  On  the  left  side  is  indicated  an  abscess  involving  the  ovary  only,  which  is  a  much 
rarer  condition. 

affected  tube.  If  the  inflammation  is  more  marked,  there  is  a  distinct  mass 
beside  the  uterus  in  the  tubal  region,  fixing  the  uterus  to  the  pelvic  wall. 
If  the  inflammation  is  still  more  marked,  the  posterior  cul-de-sac  contains 
a  mass  of  exudate,  or  the  whole  pelvis  may  be  filled  with  a  mass,  which 
forms  a  wall  above  the  place  of  the  vagina  (Figs.  377,  378),  and* the  uterus 
is  fixed  immovablv  in  this  roof  of  exudate.     The   exudate  is  tender  when 


842 


PELVIC   INFLAMMATION 


pressed  upon  and,  if  there  is  a  large  collection  of  pus,  fluctuation  may  be 
felt  in  the  cul-de-sac  of  Douglas  or  in  the  tubal  region  of  one  side.  The 
uterus  is  fixed,  and  attempts  to  move  it  cause  pain.  The  amount  of  fixation 
or  limitation  of  movement  depends,  of  course,  on  the  extent  of  the  exudate 
and  adhesions. 


Fig. 


Double    Hydrosalpinx.      The    sectioned    right    tube    indicates   clearly    the    marked    thinning    of    the 
wall  found  in  these  cases. 


The  cases  of  chronic  salpingitis  frequently  present  also  complications — 
laceration  of  pelvic  floor,  laceration  of  cervix,  retroversion  of  uterus  and 
chronic  endometritis.  These  conditions  should  be  searched  for  and  noted,  for 
they  must  be  taken  into  consideration  in  the  treatment. 


CHRONIC   PELVIC    CELLULITIS 


843 


(B)   CHRONIC  PELVIC  CELLULITIS  (PARAMETRITIS) 

This  is  chronic  inflammation  of  the  connective  tissue  surrounding  the 
uterus.  There  is  usually  more  or  less  secondary  infiltration  of  the  connec- 
tive tissue  in  all  extensive  pelvic  inflammations,  and  sometimes  pus  of  tubal 
origin  will  make  its  way  into  the  connective  tissue.  But  most  of  the  cases 
of  well-marked  cellulitis  are  due  to  extension  of  infection  directly  from  the 
uterus  into  this  region. 


to^A'.'^f^feSS 


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lV^-- 


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vy 


Fig.  .689.  Hydrosalpinx.  Notice  how  the  pres- 
sure of  the  fluid  destroys  the  mucosal  folds,  leaving 
only    a    few    remnants. 


Fig.  690.  Hydrosalpinx.  This  shows,  under 
higher  power,  the  small  fold-remnants  at  the  top  in 
Fig.    689. 


Etiology 

Chronic  cellulitis  is  due  to  a  preceding  acute  cellulitis  and  consequently 
has  the  same  causative  factors.  It  is  usually  due  to  infection  following  la- 
bor or  miscarriage,  the  bacteria  passing  directly  through  the  M'all  of  the 
uterus  into  the  connective  tissue  or  through  tears  of  the  cervix.  In  other 
cases  it  can  be  traced  to  operation  on  the  cervix,  to  operation  Avithin  the 
uterus,  to  instrumental  examination  of  the  interior  of  the  uterus,  or  to  at- 
tempts at  abortion.  Cellulitis  alone  (without  tubal  involvement)  is  usually 
due  to  the  streptococcus,  staphylococcus  or  colon  bacillus — practically  never 


844 


PELVIC   INFLAMMATION 


to  the  gonococcus.     This  point  is  further  discussed  under  the  subject  of  the 
operative  treatment  of  these  masses. 

Pathology 

Pelvic  cellulitis,  like  inflammation  of  connective  tissue  elsewhere,  is  es- 
sentially an  acute  or  subacute  lymphangitis,  running  its  course  and  ending: 
in  resolution  or  abscess  formation,  or  a  mass  of  unabsorbed  exudate  and  in- 
filtration, which  may  or  may  not  conceal  a  focus  of  pus  in  its  interior.  Oc- 
casionally the  infection  will  progress  through  the  wall  of  the  uterus  as  a 
thrombo-phlebitis  and  later  break  through  the  broad  ligament  veins  into  the 
connective  tissue.  The  condition  in  any  particular  case  may  vary  from  a  small 
area  of  induration  on  one  side  of  the  cervix  to  extensive  induration,  involv- 


F;g.   691.     Nodular    Salpingitis.      This    form    of    chronic    salpingitis    is    usually   bilateral,    and    is    often 
accompanied  by  prolapse  of  the  tube  or  ovary  on  one  or  both  sides. 

ing  the  connective  tissue  all  around  the  uterus  and  extending  out  to 'the 
pelvic  wall  on  each  side  (Fig.  693).  The  process  may  extend  forward  into 
the  connective  tissue  beside  the  bladder,  or  back^vard  along  the  sacro-uterine 
ligaments.  Fig.  694  shows  various  situations  in  Avhich  the  mass  may  be 
found. 


Symptoms 

The  symptoms  are  much  the  same  as  those  due  to  salpingitis — namely, 
backache,  pain  in  the  loAver  abdomen,  tenderness  in  pelvis  and  menstrual  dis- 


CHRONIC   PELVIC    CELLULITIS 


845 


Fig.  692.  Multiple  Adhesions  from  Chronic  Pelvic  Inflammation.  This  illustration  represents  a 
posterior  view  of  the  pelvic  organs,  with  the  intestinal  coils  pushed  upward  and  to  the  sides  to  show  the 
numerous  adhesions. 


Fig.  693.  Pelvic  Cellulitis  (Parametritis).  The  broad  ligament  inflammatory  mass  is  represented  as 
sectioned  longitudinally  on  the  right  side  and  transversely  on  the  left  side.  The  former  (right  side  of  pelvis) 
indicates  how  the  infiltration  extends  down  along  the  cervix  and  vaginal  wall,  and  the  latter  (left  side) 
indicates  how  it  extends  forward  to  the  bladder  and  backward  to  the  peritoneal  cul-de-sac,  causing  a  convexity 
toward  the  cavity  of  the  cul-de-sac. 


846 


PELVIC   INFLAMMATION 


turbances.     The  severe  exacerbations,  so  characteristic  of  salpingitis,  are  not 
present  usually  in  cellulitis,  unless  there  is  complicating  salpingitis. 

On  examination,  induration  of  extreme  hardness  is  felt  very  low  in  the 
pelvis  and  closely  attached  to  the  sides  of  the  cervix — the  portion  of  the 
uterus  in  contact  with  the  connective  tissue  (Fig,  693).  The  marked  indura- 
tion may  extend  out  to  the  pelvic  wall,  and  may  be  so  intimately  attached  to 
the  bone  and  so  hard  as  to  appear  to  be  a  bony  or  cartilaginous  outgrowth 
from  the  wall  of  the  pelvis.  Other  points  in  the  differential  diagnosis  between 
a  parametritic  mass  and  a  tubal  mass  are  given  on  page  860.  In  some"  cases 
in  which  it  is  difficult  to  determine  certainly  whether  the  induration  is  in  the 
connective  tissue  or  about  the  tube,  the  history  of  the  trouble^— its  cause  and 
subsequent  course — will  help  in  distinguishing  between  the  two. 


Fig.  694.  Indicating  the  Various  Situations  in  which  a  Parametritic  Mass  may  be  found.  A,  close  to 
the  side  of  the  cervix;  B,  at  the  middle  of  the  broad  ligament;  C,  at  the  outer  portion  of  the  broad  ligament; 
D,  in  the  sacro-uterine  ligament  close  to  the  cervix;  B,  in  the  posterior  portion  of  the  sacro-uterine  ligament; 
F,  at  the  side  of  the  bladder;   G,  in  the  anterior  portion  of  the  pelvis. 


(C)  CHRONIC  OOPHORITIS 

Chronic  inflammation  of  the  ovary  may  be  secondary  or  primary.  Second- 
ary inflammation  of  the  ovary  is  due,  as  a  rule,  to  extension  from  a  sal- 
pingitis. The  inflammation  about  the  outer  end  of  the  tube  involves  the  ad- 
jacent peritoneum  and  ovary.  When  this  takes  place  the  following  conditions 
in  the  ovary  may  result : 

1.  One  or  more  points  of  infection,  Avith  inflammation,  inflltration  and 
swelling— the  inflammation  involving  both  the  follicles  and  the  interfollicular 


CHRONIC   OOPHORITIS 


847 


connective  tissue.  It  may  or  may  not  progress  to  the  stage  of  abscess  forma- 
tion. When  an  ovarian  abscess  forms,  it  is  usually  in  connection  with  tubal 
suppuration,  hence  it  was  considered  along  with  salpingitis  (page  836  and 
Fig.  687). 

2.  The  ovary,  instead  of  becoming  infected,  may  simply  become  sur- 
rounded by  exudate,  which  compresses  it,  damaging  it  and  causing  cellular  infil- 
tration of  the  connective  tissue  (both  the  capsule  and  stroma).  In  time  this 
round  cell  infiltration  forms  scar-tissue,  and  as  it  contracts  it  further  inter- 
feres with  the  Graafian  follicles,  so  that  they  atrophy  or  form  small  cysts. 
From  this  process  the  functionating  part  of  the  ovary  becomes  reduced  in 
size,  and  the  organ  may  come  to  consist  simply  of  a  mass  of  fibrous  tissue  with 
small  cysts  scattered  through  it.  This  condition  is  called  cirrhosis,  and  ovaries 
thus  affected  are  designated  as  '* cirrhotic  ovaries." 


Fig.  695.     Cystic  Ovary. 


This   affection   is   usually   bilateral,   and  the   chronically  inflamed   and   heavy   ovary 
is  often  prolapsed. 


Primary  inflammation  of  the  ovary  is  due  to  infection  carried  by  the 
blood  or  to  active  hyperemia  (from  excessive  sexual  excitement  or  suppres- 
sion of  menses),  or  to  interference  with  the  circulation  (from  malposition,  or 
from  chronic  inflammation  of  the  uterus  or  tubes,  or  from  a  tumor  of  the 
uterus,  or  from  other  pelvic  t\imor).  In  the  case  of  infection  the  inflamma- 
tion runs  th©  same  course  as  in  oophoritis,  secondary  to  salpingitis. 

In  the  case  of  oophoritis  due  to  circulatory  disturbance  without  infec- 
tion, the  process  is  really  not  inflammation,  but  a  nutritive  disturbance  accom- 
panied v/ith  chronic  irritation.  There  is  chronic  congestion  of  the  ovary, 
round  cell  infiltration  and  enlargement,  with  dilatation  of  the  Graafian  fol- 


848  PELVIC  iis'fla:m:mation 

licles.  This  produces  a  large,  heavy,  tender  "cystic  ovary"  (Fig.  695).  The 
heavy  ovaiy  is  very  liable  to  sink  dovn  back  of  the  uterus,  low  in  thp.  pelvis, 
a  condition  kno'\^'n  as  "prolapse  of  the  ovary."  Later,  owing  to  the  con- 
tra,ction  of  the  newly -formed  connective  tissue,  the  ovary  may  shrink  and  be- 
come cirrhotic. 

The  normal  changes  in  the  ovary,  incident  to  the  rupture  of  the  Graafian 
follicles  and  subsequent  scar  formation  (see  I^hapter  xii),  produce  appear- 
ances which  are  sometimes  mistaken  for  inflammation.  '      " 

The  symptoms  of  infective  inflammation  of  the  ovaiy  are  about  the  same 
as  those  of  salpingitis.  In  the  non-infective  inflammatory  disturbances' above 
referred  to  (hyperplasia  of  ovary,  cystic  ovary,  cirrhotic  ovary,  prolapse  of 
ovary)  the  symptoms  are  much  the  same  as  in  a  chronic  salpingitis,  but 
without  the  severe  exacerbations,  confining  the  patient  to  bed  for  one  or 
two  weeks.  The  symptoms  approach  those  of  a  neuralgic  rather  -fhan  an 
inflammatory  character.  The  patient  is  rarely,  if  ever,  confined  to  bed  more 
than  a  few  hours,  except  in  some  cases  at  the  menstrual  periods.  Examina- 
tion shows  no  mass  of  exudate  about  the  tube,  but  one  or  both  ovaries  are 
enlarged  and  very  tender,  and  possibly  prolapsed.  In  a  later  stage  the  en- 
larged ovarj^  may  shrink  and  become  smaller  than  normal  (cirrhotic  ovary). 

DIFFERENTIAL   DIAGNOSIS   OF   CHRONIC   PELVIC   INFLAMMATION 

The  diseases  which  may  be  confounded  with  chronic  pelvic  inflamma-tion, 
and  which  therefore  must  be  taken  into  consideration  in  the  differential 
diagnosis,  are  as  follows  :  ;  • 

Chronic   endometritis.  :. 

Fibromyoma  of  the  uterus. 

Tubal  pregnancy,  with  chronic  symptoms. 

Tuberculosis  of  the  tubes  and  peritoneum. 

Syphilis  of  the  pelvic  structures. 

Ovarian  and  broad  ligament  tumors. 

Chronic  appendicitis. 

Mucous  colitis. 

Bladder  and  rectal  affections. 

Pelvic  neuralgia. 

Neurasthenia. 

Hysteria. 
In  chronic  endometritis,  without  pelvic  inflammation,  the  trouble  is  con- 
fined to  the  uterus,  and  consequently  there  is  no  marked  tenderness  nor  any 
inflammatory  mass  outside  the  uterus. 

A  fibroid  tumor  of  the  uterus  usually  presents  the  following  points : 

a.  The  symptoms  are  of  gradual  onset,  and  consist  principally  of  men- 
strual disturbances,  particularly  increased  flow. 

b.  Absence  of  fever  and  absence  of  attacks  of  pelvic  peritonitis. 


DIFFERENTIAL   DIAGNOSIS  849 

c.  The  mass  is  hard,  has  a  definite  and  rounded  outline,  is  intimately  con- 
nected T  ith  the  uterus  and  not  attached  to  the  pelvic  wall. 

d.  "^here  is  not  the  marked  tenderness  that  is  found  in  pelvic  inflamma- 
tion. 

6.  There  is  no  fixation  unless  the  tumor  is  large  enough  to  impinge  on 
the  pei  .'ic  wall.  The  uterus  and  tumor  are  movable  together,  but  not  sepa- 
rately , 

f.  .':f  necessary  to  sound  the  uterus,  it  will  usually  be  found  increased  in 
depth. 

Ovarian  and  Broad  Lig-ament  Tumors  present  the  following  characteristics: 

a.  Gradual  onset  of  symptoms. 

b.  Absence  of  fever  and  of  marked  menstrual  disturbance  and  of  severe 
attacks  of  pelvic  peritonitis. 

c.  I^arge  tumor  mass  without  particular  tenderness  and  without  fixation. 
In  the  ease  of  an  ovarian  tumor  the  mass  can  usually  be  moved  about  in  the 
lower  abdomen. 

d.  Distinct  fluctuation  without  marked  tenderness,  indicating  that  the 
fluid  is  not  pus. 

Tuberculosis  of  tubes  and  peritoneum.  The  distinguishing  characteristics 
of  tuberculosis  of  the  tubes  and  peritoneum  are : 

a.  Decided  symptoms  of  pelvic  inflammation  in  a  young  woman  who  has 
had  no  opportunity  to  contract  pelvic  inflammation — that  is,  in  a  woman  who 
has  never  had  endometritis. 

b.  Gradual  onset,  usually,  and  persistent  progress  without  the  marked 
improvement  usually  following  the  treatment  of  ordinary  pelvic  inflammation. 

c.  Encysted  ascites — a  collection  of  fluid  shut  off  from  the  general  peri- 
toneal cavity  by  adhesions — without  the  marked  pain  and  fever  that  would 
come  with  a  collection  of  pus. 

d.  Evidence  of  tuberculosis  elsewhere. 

e.  Emaciation,  gradual,  but  marked  and  persistent — more  so  than  would 
bfc.  accounted  for  by  the  pain,  fever,  etc. 

Syphilis  of  the  tubes  and  peritoneum  sufficient  to  cause  symptoms  is  rare, 
but  it  should  always  be  borne  in  mind  in  patients  presenting  marked  evidence 
of  syphilis  especially,  if  there  is  severe  ulceration  of  the  genitals  or  rectum 
or  if  there  is  stricture  of  rectum.  All  such  patients  presenting  symptoms  of 
chronic  pelvic  inflammation  should  be  given  a  thorough  course  of  potassium 
iodide  before  operation  is  decided  upon. 

It  is  the  cellular  deposit  of  the  tertiary  stage  that  attacks  these  structures. 

a.  Evidence  of  syphilis  elscAvhere  in  the  body. 
The  symptoms  pointing  to  such  trouble  are : 

b.  Gradual  onset  of  the  trouble,  usually  in  connection  with  some  other 
active  evidence  of  syphilis  in  the  third  stage. 

c.  The  reactions  for  syphilis  (Wassermann,  Noguehi)  are  positive.  Spiro- 
chetes have  never  been  seen  in  tubes. 


850  PELVIC   INFLAMMATION 

Though  this  syphilitic  condition  in  the  pelvis  is  rare,  it  occasiong,lly  oc- 
curs and  must  be  watched  for  in  syphilitics. 

Chronic  Appendicitis  may  be  difficult  to  differentiate  from  chronic  sal- 
pingitis of  the  right  side.    The  facts  pointing  to  appendicitis  are  as  follows : 

a.  High  location  of  the  painful  area,  at  McBurney's  point,  without  a 
painful  area  at  the  site  of  the  Fallopian  tube. 

b.  Stomach  and  intestinal  disturbance,  preceding  and  accompanying  an 
attack.     Also  pain  in  the  region  of  the  umbilicus,  rather  than  in  the  back. 

c.  High  location  of  the  mass  of  exudate — not  felt  so  well  from  vagina  as 
would  be  a  mass  about  the  Fallopian  tube. 

d.  Absence  of  endometritis  and  absence  of  a  history  of  previous  uterine 
sepsis  or  gonorrhea. 

e.  No  marked  increase  of  the  trouble  at  the  menstrual  periods.  Even 
appendicitis  may  show  some  increase  then,  but  it  is  not  so  marked  as  in  sal- 
pingitis. 

In  a  case  of  inflammation  in  the  right  lower  abdomen  in  a  girl,  or  in  a 
woman  who  has  never  been  pregnant  nor  had  any  uterine  infection,  the 
trouble  is  more  likely  to  be  appendicitis.  On  the  other  hand,  in  a  case  of 
inflammation  in  that  locality  in  a  woman  who  has  once  had  infection  of 
the  uterus,  the  probability  is  in  favor  of  salpingitis.  In  some  cases  it  is 
impossible  to  make  a  positive  differential  diagnosis  until  the  abdomen  is 
opened.  In  fact,  it  not  infrequently  happens  that  both  structures  are  involved 
in  the  inflammatory  process,  the  inflammation  beginning  in  the  tube  and  ex- 
tending to  the  appendix  or  beginning  in  the  appendix  and  extending  to 
the  tube. 

Other  intestinal  diseases  also  must  be  excluded.  Mucous  colitis  is  the  one 
which  has  most  frequently  been  mistaken  for  chronic  tubal  or  ovarian  in- 
flammation (see  page  340).  The  points  that  distinguish  mucous  colitis  from 
chronic  pelvic  inflammation  are  (a)  the  character  of  the  pain  (resembling 
intestinal  cramps  and  extending  throughout  the.  lower  abdomen),  (b)  the 
passage  of  characteristic  masses  of  mucus  in  some  of  the  attacks  and  (c) 
the  absence  of  any  palpable  pelvic  lesion. 

There  are  also  disease  of  the  urinary  organs  that  may  be  confounded  with 
chronic  pelvic  inflammation.  All  these  affections  must  be  excluded  by  a 
knowledge  of  the  symptoms  and  signs  that  accompany  them. 

In  pelvic  neuralgia  and  in  neurasthenia  and  in  hysteria,  without  compli- 
cating pelvic  inflammation,  there  is  no  abnormal  mass  within  the  pelvis.  In 
pelvic  neuralgia  the  tenderness  may  be  localized  along  the  pelvic  nerve 
trunks  (Figs.  83,  84). 

Treatment 

In  the  treatment  of  chronic  pelvic  inflammation  (chronic  salpingitis, 
chronic  oophoritis,  chronic  pelvic  peritonitis,  chronic  pelvic  cellulitis,  and  all 


TREATMENT   OF    CHRONIC   PELVIC   INFLAMMATION  851 

combinations  of  these  lesions)  there  are  certain  general  measures  that  are 
applicable  to  practically  all  cases,  and  there  are  also  special  measures  that 
are  applicable  to  special  conditions  only. 

GENEEAL  MEASURES 

1.  Laxatives  as  needed  to  overcome  chronic  constipation.  Cascara  sa- 
grada  is  an  excellent  laxative  for  this  purpose  after  the  bowels  have  been 
thoroughly  moved  by  some  more  active  i)urgative.  Use  the  laxative  pills 
containing  aloin,  belladonna,  strychnia  and  cascara,  one  pill  each  night  or 
one  each  night  and  morning.  For  continued  use  the  mineral  oils  (paraffine 
oil)  prove  most  suitable. 

2.  Attention  to  the  general  health,  as  indicated  by  anemia,  lithemia  or 
other  abnormal  condition.  This  is  particularly  important  in  chronic  pelvic 
diseases  if  satisfactory  results  from  treatment  would  be  secured.  Just  be- 
cause the  patient  has  some  pelvic  disease,  do  not  jump  at  the  conclusion 
that  treatment  of  that  alone  will  cure  her.  There  may  be  an  affection  in 
some  other  part  of  the  body  that  has  far  more  to  do  with  the  patient's  ill 
health.  And  even  considering  the  effect  on  the  pelvic  affection  only,  the 
general  health  should  be  built  up  as  much  as  possible. 

3.  Rest  at  the  menstrual  periods.  If  the  patient  suffers  much,  she  should 
go  to  bed  and  have  hot  applications  made  to  the  lower  abdomen.  If  this  does 
not  give  relief,  she  should  be  given  sedatives  as  necessary,  but  avoid  opium. 

4.  Hot  Vaginal  Douches,  one  to  three  times  daily.  To  secure  the  best 
result,  these  must  be  given  according  to  the  special  directions  detailed  in 
Chapter  m. 

5.  Applications  to  the  vaginal  vault.  Ichthyol  (10  per  cent)  in  glycerine 
and  applied  by  means  of  tampons  every  second  or  third  day,  aids  some  in 
relieving  the  pain  and  hastening  the  absorption  of  the  exudate. 

6.  Applications  to  the  lower  abdomen.  These  consist  principally  in  coun- 
terirritation  by  means  of  tincture  of  iodine  applied  over  the  tubo-ovarian  re- 
gion of  one  or  both  sides.  This  is  useful  particularly  in  chronic  or  subacute 
oophoritis  and  in  o^'arian  neuralgia.  The  patient  is  given  a  prescription 
for  an  ounce  bottle  of  the  tincture  and  a  camel's  hair  brush.  She  is  directed 
to  paint  the  iodine  over  the  painful  region  once  daily  until  the  skin  becomes 
tender,  then  stop  for  a  few  days  until  the  skin  irritation  subsides,  then  use 
the  iodine  again  until  the  skin  becomes  tender,  and  so  on  as  long  as  desired. 
By  this  means  mild  counterirritation  may  be  kept  up  over  the  painful 
ovary  for  weeks,  with  decided  diminution  of  pain  in   some   cases. 

SPECIAL  MEASURES 

1.  If  there  is  a  collection  of  pus  low  in  the  pelvis,  open  and  drain  it  by 
vaginal  operation,  according  to  the  technic  given  in  detail  under  acute 
pelvic   inflammation    (see   page   814).     In  the   after-treatment   the   drainage 


852  PEL^nC    IXFLAMMATIOX 

tube  will  have  to  remain  in  longer  than  for  an  acute  abscess  of  the  same 
size,  for  the  chronic  abscesses  have  thicker  walls  and  hence  collapse  more 
slowly. 

2.  If  there  is  an  inflammatory  mass  high,  which  probably  contains  pus  or 
which  continues  to  give  serious  trouble  after  a  thorough  trial  of  the  general 
measures  (that  is.  after  those  measures  have  been  used  faithfully  for  several 
weeks  along  with  rest  in  bed  as  thought  best),  then  comes  the  ciuestion  of 
abdominal  operation.  Intimately  associated  with  this  is  another  important 
question,  namely: 

What  is  the  Preferable  Time  for  Abdominal  Operation  for  a  Chronic 

Inflammatory'  Mass  in  the  Pelvis? 

In  a  considerable  proportion  of  the  cases  of  chronic  suppuration  in  the 
pelvis  the  pus  is  sterile  at  the  time  of  operation.  In  63-1:  cases  examined 
baeteriologically  (collected  by  Andrews)  the  results,  excluding  tubercular 
cases,  were  as  follows: 

Sterile 55.     per  cent 

Only  saprophytes 6.     per  cent 

Gonococcus   22.5  per  cent 

Streptococcus  and  staphylococcus 12.     per  cent 

Pneumococcus    2.     per  cent 

Bacillus  coli  communis ". 2.5  per  cent 

In  a  later  resume,  by  Hyde,  comprising  nearly  three  thousand  cases  (2973 
cases,  excluding  tubercular),  the  bacteriologic  findings  were  approximately  as 
follows:  sterile,  1998;  gonococcus,  579;  other  bacteria  and  mixed  infections, 
456. 

It  is  interesting  to  note  the  steps  in  the  development  of  this  knowledge. 
Long  ago  it  was  observed  that,  of  the  patients  subjected  to  abdominal  oper- 
ation for  pelvic  suppuration,  the  old  cases  usually  recovered  promptly,  while 
the  recent  cases  frecpiently  developed  fatal  peritonitis — that  is,  operation  in 
the  acute  stage  was  far  more  dangerous  than  operation  in  the  chronic  stage. 

The  splendid  advance  in  gynecologic  work  in  the  last  few  decades  is 
based  on  facts  ascertained  in  two  ways.  Some  facts  came  to  the  surface 
laro'ely  through  pathologic  and  bacteriologic  investigations,  while  others  were 
ascertained  by  experience  at  the  operating  table  and  the  bedside.  The  fact 
above  referred  to  belongs  to  the  latter  class ;  it  was  learned  by  experience, 
often  bitter  experience,  and  many  lives  were  lost  before  the  lesson  was  fully 
learned. 

This  fact,  after  having  been  clinically  established,  was  the  occasion  of 
much  curiosity,  as  the  explanation  was  not  at  hand.  It  seemed  paradoxical 
that  long  continuance  of  a  debilitating  disease  should  put  the  patient  in  bet- 
ter condition  for  a  serious  operation  for  the  same. 


TREATMENT   OF    CHRONIC   PELVIC   INFLAMMATION  853 

What  could  be  the  explanation?  Why  did  chronic  inflammation  confer 
such  immunity  from  peritonitis  after  operation?  One  early  theoiy  was  that 
the  immunity  was  due  largely,  if  not  wholly,  to  the  local  effect  on  the  adja- 
cent peritoneum,  choking-  its  absorptive  channels  so  that  septic  absorption 
could  not  take  place  so  readily,  and  modifying  the  membrane  so  that  it 
was  not  as  good  culture  ground  for  the  bacteria.  According  to  another  hypoth- 
esis the  body  resistance  generally  became  ''accustomed"  to  the  local  irri- 
tation in  the  pelvis  and  consequently  was  less  disturbed  by  the  added  irrita- 
tion of  operation,  and  also,  owing  to  the  preparedness,  so  to  speak,  of  the 
general  resistant  forces  of  the  body,  they  were  better  able  to  combat  invasion. 
These  explanations  were  but  gropings  in  the  dark,  but  nevertheless  they  con- 
tained truths  which  have  been  verified  and  elucidated  by  the  epoch-making  in- 
vestigation into  the  resistant  functions  of  the  leucocytes  and  the  blood  serum, 
and  into  the  modus  operandi  of  antitoxin  and  vaccine  therapy. 

The  decisive  step  in  tlie  solution  of  the  riddle  was  the  inauguration  of 
systematic  bacteriologic  examination  of  specimens  removed  in  operations 
for  pelvic  suppuration.  These  bacteriologic  examinations  were  undertaken 
primarily  for  the  purpose  of  determining  the  etiology  of  salpingitis,  particu- 
larly what  proportion  of  the  cases  were  due  to  the  gonococeus  and  what 
proportion  to  other  bacteria.  The  results  were  disappointing.  In  a  consider- 
able proportion  of  the  cases  no  bacteria  could  be  found  and  hence  in  those 
cases  the  etiology  of  the  trouble  could  not  be  bacteriologically  determined. 
But,  though  disappointing  so  far  as  concerned  the  definite  etiologic  classifica- 
tion of  cases,th6  facts  thus  ascertained  were  very  illuminating  in  regard  to 
the  important  and  puzzling  question  as  to  why  immunity  was  secured  by 
waiting.  In  many  cases  the  bacteria  had  died  and  disintegrated  and  the  pus 
was  sterile — that  was  the  reason  serious  inflammation  seldom  followed  ab- 
dominal section  for  old  tubal  abscesses,  even  though  considerable  pus  often 
escaped  among  the  pelvic  structures  during  the  enucleation.  On  the  other 
hand,  in  fresh  cases  the  least  peritoneal  contamination  by  the  contained  pus 
was  often  followed  by  fatal  peritonitis  because  the  bacteria  Avere  not  dead, 
but  active  and  virulent.  Another  fact  ascertained  was  that  in  many  of  the 
old  cases  in  which  bacteria  were  still  present  they  were  so  atenuated  that  the 
pus  was  practically  sterile. 

Persistence  of  Virulence — Classification  of  Cases 

It  having  been  established  that  sterilization  gradually  takes  place  within 
a  reasonable  time  in  most  cases,  the  next  problem  is  to  determine  the  period 
of  time  required  for  the  automatic  sterilization  or  effective  attenuation  in 
the  different  classes  of  cases. 

The  persistence  of  virulence  depends  largely  on  the  character  of  the 
infection.  The  two  principal  infectious  agents  in  jDelvic  inflammatory  masses 
are  the  gonococeus  and  the  streptococcus.     These  two  differ  widely  in  the 


854  PELVIC   INFLAMMATION 

persistence  of  virulence  and  also  in  certain  clinical  characteristics  which  can 
be  distinguished  before  operation. 

For  the  purpose,  then,  of  considering  the  persistence  of  virulence  in  a 
practical  way  — i.  e.,  as  a  guide  to  treatment — the  cases  of  chronic  pelvic  sup- 
puration (tubercular  excluded)  may  be  divided  into  tAvo  classes — the  gono- 
coccic  and  the  streptococcic.  To  be  useful,  this  classification  must  be  made 
before  operation — that  is,  it  must  be  a  clinical  rather  than  a  strictly  bacterio- 
logic  classification.  Of  course,  from  a  bacteriologic  standpoint  there  are  other 
cases,  due  to  other  bacteria,  but  in  the  present  state  of  knowledge  these  other 
cases  can  not,  as  a  rule,  be  distinguished  before  operation,  and,  even  if  they 
were  distinguished,  not  enough  information  has  accumulated  to  show  the  aver- 
age persistence  of  virulence  in  such  cases.  Consequently,  when  confronted 
with  a  case  of  non-tubercular  chronic  pelvic  inflammation,  the  endeavor  should 
be  to  decide  whether  it  belongs  to  the  gonococcic  or  streptococcic  class,  ignor- 
ing for  the  time  the  fact  that  it  may  possibly  be  due  to  other  bacteria,  which 
in  point  of  virulence  lie  between  these  two  extremes. 

How  may  the  gonococcic  and  the  streptococcic  cases  be  distinguished  be- 
fore operation?  What  diagnostic  facts  are  available  at  that  time?  Bacte- 
riologic examination  of  the  urethral  or  uterine  or  other  discharge  is  of  as- 
sistance in  only  a  small  proportion  of  these  chronic  cases,  for  as  a  rule  the  bac- 
teria have  disappeared  from  the  discharge.  Neither  is  there  at  present  any 
well-established  specific  diagnostic  reaction  in  gonococcus  or  streptococcus 
cases  corresponding  to  the  tubercular  reaction  in  tubercular  cases.  Hence 
we  must  depend  on  other  information  obtainable  before  operation.  Fortu- 
nately the  gonorrheal  cases  and  the  streptococcal  cases  differ  usually  in  two 
particulars;  namely,  (a)  in  the  apparent  cause  of  the  trouble  and  (b)  in  the 
location  of  the  lesion.  As  a  rule  these  distinguishing  points  may  be  settled 
and  the  case  definitely  classified  by  an  accurate  inquiry  into  the  onset  of  the 
trouble  and  a  careful  bimanual  examination. 

Uncertain  cases  are  to  be  classed  with  one  or  the  other,  as  the  preponder- 
ance of  evidence  warrants,  and  are  to  be  given  treatment  accordingly.  After 
operation,  bacteriologic  examination  may  show  other  bacteria,  either  alone 
or  associated,  and,  if  accurate  records  are  kept  of  the  histories  and  bacterio- 
logic findings  in  large  series  of  cases,  it  may  be  possible  later  to  form  a  third 
clinical  class,  comprising  one  or  more  of  the  miscellaneous  or  mixed  infec- 
tions. For  the  present,  however,  the  two  classes,  gonococcic  and  streptococ- 
cic, are  all  that  can,  as  a  rule,  be  satisfactorily  distinguished  before  operation. 

Gonococcic  Class  (Clinical) 

In  the  gonococcic  class  (clinical)  the  distinguishing  points  are:  (1)  that 
the  pelvic  inflammation  is  preceded  by  evidence  of  gonorrhea  or  comes  on 
without  apparent  cause,  and  (2)  that  the  lesion  is  located  in  the  tube,  ex- 
tending thence  to  the  ovary  or  adjacent  peritoneal  surfaces,  but  not  involving 


TREATMENT   OF    CHRONIC   PELVIC   INFLAMMATION  855 

the  connective  tissue  (parametrium)  to  any  decided  extent.  As  so  much 
diagnostic  importance  is  attached  to  these  two  points,  it  is  necessary  to  con- 
sider them  somewhat  in  detail. 

a.  Apparent  cause  or  mode  of  onset.  As  a  general  proposition  it  may  be 
said  that  the  gonococcus  is  the  only  germ  that  will  spontaneously  invade  the 
normal,  non-puerperal  uterus  and  tubes.  There  are  exceptions.  Eiedel  re- 
ported that  of  56  girls  under  ten  years  of  age  operated  on  for  appendicitis, 
five  had  peritonitis  due,  not  to  appendicitis,  but  to  acute  salpingitis.  He 
states  positively  that  the  infections  reached  the  tubes  by  way  of  the  vagina 
and  uterus,  and  that  gonorrhea  was  excluded  in  every  case.  Cultures  showed 
the  ordinary  pus  germs.  The  inflammation  was  virulent  and  every  patient 
died  in  spite  of  operative  treatment.  He  observed  the  same  clinical  picture 
in  two  girls  past  ten  years  of  age,  both  of  whom  died.  In  contradistinction 
to  these  cases  in  children,  he  states  that  he  has  never  seen  such  penetration  of 
normal  genitals  by  streptococci  or  staphylococci  in  the  adult. 

General  experience  is  in  accord  with  this  statement  in  regard  to  adults. 
Purulent  inflammation  beginning  in  a  normal  adult  non-puerperal  vagina  or 
uterus,  and  later  extending  out  into  the  pelvic  cavity,  may  be  set  down  as 
almost  certainly  gonorrheal.  The  patient  must,  of  course,  be  questioned 
closely  enough  to  eliminate  an  early  miscarriage  and  also  any  intrauterine 
instrumentation  (curetment,  intrauterine  treatment,  sounding  in  examina- 
tion, etc.)  The  probability  of  gonorrhea  is  increased  if  the  purulent  dis- 
charge (''free  leucorrhea")  began  within  a  few  weeks  after  marriage.  Again, 
in  a  large  proportion  of  the  cases  of  gonococcal  leucorrhea  there  is  urethritis, 
causing  burning  on  urination  and  increased  frequency  of  urination.  This 
discharge  and  disturbance  of  micturition  may  last  a  few  days  or  much  longer. 
It  may  precede  the  pelvic  inflammation  by  a  few  days  or  a  few  weeks  or  a 
few  months.  A  history  of  abscess  of  one  of  the  vulvo-A^aginal  glands  has 
about  the  same  significance  as  a  history  of  urethritis.  These  structures  are 
frequently  involved  in  gonococcal  leucorrhea,  but  very  seldom  in  leucorrhea 
from  other  causes. 

In  those  cases  where  the  vaginal  and  uterine  gonorrhea  did  not  cause 
sufficient  disturbance  to  be  noticed,  the  pelvic  inflammation  began  without 
apparent  cause.  A  considerable  proportion  of  the  gonorrheal  cases  give  such 
a  history.  Here,  again,  one  must  be  careful  not  to  overlook  an  early  miscar- 
riage or  some  intrauterine  instrumentation.  Also,  it  is  important  to  trace 
the  inflammation  back  to  its  very  beginning,  for  some  cases  of  puerperal  in- 
fection are  very  mild  in  outward  manifestations  and  do  not  cause  much 
trouble  until  there  is  an  exacerbation  after  several  weeks  or  months.  ..In 
these  cases,  however,  there  is  usually  a  history  of  some  disturbance  during 
the  puerperium,  from  which  the  patient  recovered  to  a  large  extent,  but  not 
entirely.  On  the  other  hand,  an  inflammatory  trouble,  at  first  apparently  due 
to  a  miscarriage  or  full  term  delivery,  may  on  careful  questioning  be  found 
to  antedate  the  pregnancy  and  to  be  due  to  a  preceding  gonorrheal  infection. 


856  PELVIC    INFLAMMATION 

In  the  examination  a  search  should  be  made  about  the  external  genitals 
for  evidences  of  an  old  gonorrhea — signs  of  previous  inflammation  of  the 
urethra  or  of  the  vulvo-vaginal  glands,  such  as  red  spots  (maculae  gonor- 
rhoicae)  in  these  situations,  or  secretion  that  can  be  pressed  from  the  struc- 
tures. Bacteriologic  examination  of  discharge  from  the  urethra,  vulvo- 
vaginal glands,  vagina  or  cervix  may  show  gonocoeci.  Negative  findings, 
however,  do  not  exclude  gonorrhea,  for  in  many  of  the  chronic  cases  the 
causative  bacteria  have  disappeared  from  the  discharge. 

In  a  certain  proportion  of  cases  of  gonococcic  pelvic  inflammation,  the  ex- 
tensions of  the  gonocoeci  into  the  uterus  and  beyond  took  place  during  the 
puerperium.  It  has  been  shown  that  the  gonococcus  may  lie  practically  dor- 
mant in  the  lower  part  of  the  genital  tract  for  a  long  time  and  extend  up- 
ward after  a  labor  or  miscarriage.  Saenger  examined  389  pregnant  women 
and  found  the  gonococcus  in  100.  Steinbuechel  examined  the  lochia  in  274 
women  in  which  the  puerperium  was  normal  and  found  the  gonococcus  in  18 
per  cent.  In  Leopold's  clinic,  25  per  cent  of  the  puerperal  infections  were  of 
gonorrheal  origin.  In  179  cases  of  puerperal  sepsis  examined  bacteriologi- 
cally  by  Kroenig,  50  cases  were  gonococcal,  50  belonged  to  the  sapremic  group 
(miscellaneous  saprophytes,  most  of  Avhich  did  not  grow  in  ordinary  cul- 
ture media)  and  79  were  due  to  the  ordinary  pus  bacteria.  Puerperal  in- 
fection due  to  the  gonococcus  is  nearly  always  of  a  mild  type,  as  shown  in  an 
instructive  article  by  Taussig.  A  history  indicating  that  the  attack  of  puer- 
peral sepsis  was  mild  may  help  some  in  differentiation,  though  it  must  be 
kept  in  mind  that  puerperal  infection  from  other  bacteria  may  also  run  a 
mild  course.  In  the  cases  of  puerperal  origin,  therefore,  without  positive  evi- 
dence of  gonorrhea,  the  decision  must  rest  largely  on  the  location  of  the 
lesion. 

b.  Location  of  the  lesion.  The  extension  of  gonorrheal  inflammation  is 
almost  invariably  along  the  uterine  mucosa  into  the  tube  (Fig.  696),  and  any 
further  extension  is  toward  the  ovary  and  the  peritoneal  cavity.  Gonocoeci 
very  seldom  extend  through  the  uterine  wall  into  the  parametrium.  Even 
when  they  do  extend  into  the  connective  tissue,  they  are  not  likely  to  form 
an  inflammatory  mass  there.  Steinschneider  and  Schaefer  injected  pure  cul- 
tures of  gonocoeci  into  connective  tissue,  but  no  decided  inflammatory  action 
resulted.  Though  parametria!  abscess  may  occasionally  result  from  gono- 
coeci, as  demonstrated  by  Wertheim  and  others,  it  is  so  rare  as  to  be  a 
curiosity. 

The  characteristic  lesion,  therefore,  of  gonorrhea  in  the  pelvis  is  pyosal- 
pinx,  with  or  without  the  complicating  oophoritis  and  pelvic  peritonitis.  The 
great  majority  of  all  pus  tubes  are  due  to  gonorrheal  infection,  known  or 
unknown.  In  106  eases  of  purulent  salpingitis  examined  by  Menge  the  find- 
ings were  as  folloAvs:  sterile  pus  in  68,  gonocoeci  in  22,  tubercle  bacilli  in  9, 
staphylococcus  in  1,  anaerobic  bacteria  in  2,  and  streptococci  in  4.  As  we 
shall  see  later,  the  gonococcus  often  dies  out  within  a  comparatively  short 


TREATMENT   OF    CHRONIC    PELVIC    INFLAMMATION 


857 


time,  so  it  is  probable  that  most  of  the  sterile  eases  originate  from  the  gono- 
eoeciis.  When  this  fact  is  taken  into  consideration,  it  becomes  apparent  what 
a  large  proportion  of  the  cases  of  purulent  salpingitis  are  due  to  the  gono- 
coceus  and  what  a  small  proportion  to  other  bacteria. 

In  an  article  on  this  subject*  the  author  gave  the  details  of  a  series  of 
cases  of  the  gonococcic  class  (clinical),  showing  the  tM'o  principal  diagnostic 
points  before  operation,  the  interval  of  time  from  infection  to  operation,  the 
bacteria  found  at  operation,  and  the  degree  of  virulence  (as  indicated  by  the 
result  of  the  operation). 

The  cases  thus  tabulated  in  detail  may  be  taken  as  typical  of  the  hun- 
dreds of  cases  of  this  common  class,  which  include  probably  five-sixths  of  the 
chronic  inflammatory  masses  in  the  pelvis.     These  cases  are  so  common  and 


Fig.   696.     Gonococcal   Infection   of   Uterus   and    Resulting   Lesion.      Gonococcal   inflammation   extends    along 
the  mucosa  to  the  tube  (as  indicated  in  left  side),  and  causes  pyosalpinx   (right  side). 


run  such  a  uniform  course  that  but  few  are  reported  in  sufficient  detail  to 
show  definitely  the  apparent  cause,  the  interval  of  time  from  infection  to 
operation,  the  location  of  the  lesion  and  the  bacteriologie  findings.  It  would 
be  well  if  several  series  from  the  larger  clinics  were  reported,  so  as  to  show 
the  points  mentioned,  that  the  preoperative  diagnosis  of  the  character  of  the 
infection  and  the  probable  virulence  may  be  more  clearly  defined. 

It  will  be  noticed  in  the  article  mentioned  that  in  some  of  the  cases 
belonging  clinically  to  the  gonococcic  class,  bacteriologie  examination. showed 
other  bacteria  instead  of  the  gonococcus.  But  they  are  placed  in  this  clinical 
class  because  of  the  apparent  cause  and  the  location  of  the  lesion — the  only 


"■published  in  Surgery,  Gynecology  and  Obstetrics,  October,   1909. 


858  PELVIC   INFLAMMATION 

decisive  information  usually  obtainable  before  operation.  It  is  only  by  such 
careful  classification  of  the  cases  before  operation  and  careful  bacteriologic 
examination  after  operation,  that  a  useful  classification  can  be  established 
and  errors  gradually  eliminated.  I 

The  lessons  to  be  drawn  from  the  consideration  of  the  cases  of'?tlie  gono- 
coecic  class  (clinical)  may  be  stated  briefly  under  three  heads,  as  follows: 

Reliability  of  the  Diagnostic  Points  Available  Before  Operation.  From 
the  cases  here  cited,  which  are  typical  of  the  hundreds  belonging  to  this  class, 
it  is  evident  that  the  tAvo  points  mentioned  (the  apparent  cause  and  the  loca- 
tion of  the  lesion)  may  be  depended  upon  to  eliminate  the  virulent  streptococ- 
cal cases.  Where  these  two  clinical  signs  agreed,  bacteriologic  examination 
of  the  pus  found  showed  either  the  gonococcus  or  absence  of  bacteria,  with 
but  one  exception.  This  exceptional  case  was  rather  acute  and  appeared 
gonorrheal.  The  trouble  began  shortly  after  marriage  with  a  purulent 
vaginal  discharge  and  local  irritation.  The  discharge  was  not  examined  bac- 
teriologically.  An  adnexal  mass  appeared  on  each  side  and  extended  into 
the  cul-de-sac.  The  pus  pockets  in  the  pelvis  were  evacuated  by  vaginal  in- 
cision. Pus  was  found  in  the  cul-de-sac  and  in  both  tubes.  It  was  supposed 
to  be  gonorrheal.  Bacteriologic  examination  showed  pneumococci  in  abun- 
dance, but  no  gonoccocci.  In  the  cases  where  the  two  points  did  not  agree, 
there  were  various  bacteriologic  findings.  In  uncertain  cases  the  location  of 
the  lesion  was  principally  depended  upon  for  classification.  Except  where 
the  trouble  was  clearly  from  puerperal  sepsis,  a  marked  tubo-ovarian  mass 
without  parametrial  involvement  admitted  the  case  to  this  clinical  class.  In 
no  instance  did  such  a  case  show  streptococci. 

In  the  cases  due  to  puerperal  sepsis  great  care  should  be  exercised  in 
excluding  streptococci  before  admitting  the  ease  to  the  gonoeoccic  clinical 
class.  The  apparent  location  of  the  lesion  helps,  but  can  not  be  depended 
upon  entirely  in  these  puerperal  cases.  A  few  cases  sho^^dng  streptococci 
presented  masses  at  first  supposed  to  be  purely  adnexal.  Most  of  these,  how- 
ever, on  more  thorough  examination  at  the  time  of  operation,  showed  that 
the  process  was  located  partly  in  the  connective  tissue.  Streptococcal  pyosal- 
pinx  without  associated  parametritis  is  certainly  very  rare.  Miller,  who  re- 
ported a  number  of  streptococcal  infections  and  investigated  bacteriologi- 
cally  more  than  a  hundred  cases  of  pehic  inflammation  at  Johns  Hopkins 
Hospital,  stated  that  he  had  never  encountered  a  frank  pyosalpinx  due  to 
the  streptococcus.  Whiteside  and  Walton,  in  a  series  of  thirty  cases  of  pyo- 
salpinx examined  for  bacteria,  found  the  streptococcus  in  three,  but  the 
question  of  coincident  parametrial  involvement  does  not  seem  to  have  been 
investigated.  In  a  series  of  106  cases  of  suppurative  salpingitis,  Menge  dem- 
onstrated the  streptococcus  in  4,  but  nothing  definite  is  said  as  to  the  para- 
metrial involvement  in  these  cases. 

Persistence  of  Virulence.  In  the  clearly  gonoeoccic  cases  the  bacteria 
were  found  to  be  absent  or  attenuated,  as  a  rule  within  two  to  four  months 


TKEATMENT   OF    CHRO^^C   PELVIC   INPLAMIMATION  859 

after  infection.  In  some  cases  gonococci  were  found  after  several  months  or 
a  year  or  even  several  years,  but  they  had  lost  their  virulence.  Hartman  and 
Morax  state  that  all  their  specimens  showing  gonococci  were  from  patients 
with  rather  recent  inflammation,  the  duration  of  the  trouble  varying  from 
three  weeks  to  four  months,  and  averaging  four  to  five  weeks. 

Gonococci  may  die  and  disappear  within  a  few  weeks.  In  two  cases 
detailed,  where  examination  of  the  pus  showed  it  to  be  sterile,  the  duration 
of  the  trouble  was  only  two  months  in  one  case  and  five  weeks  in  another. 
Gonocoecic  pus  confined  in  the  tube  may  become  sterile  in  six  or  eight  weeks, 
but  it  may,  on  the  other  hand,  continue  active  for  a  considerably  longer  time. 
Radical  operation,  therefore,  should  ordinarily  be  postponed  to  at  least 
three  months  from  the  onset  of  the  trouble. 

Why  Wait  for  Sterilization  or  Attenuation  in  Gonococcal  Cases.  There 
are  two  reasons.  In  the  first  place,  a  considerable  proportion  of  the  pelvic 
inflammatory  masses  disappear  without  operation  if  Nature  is  given  a  chance 
for  three  or  four  months.  Many  cases  of  supposed  pyosalpinx  so  recover. 
The  expression  ''supposed  pyosalpinx"  is  used  advisedly.  It  is  not  necessary 
to  enter  into  the  controversy  over  the  possibility  of  the  spontaneous  cure  of 
pyosalpinx,  hence  the  statement  can  be  limited  to  the  inflammatory  masses 
supposed  to  be  pyosalpinx,  of  which  undoubtedly  a  considerable  proportion 
disappear  when  Nature  is  given  a  reasonable  chance. 

The  second  reason  for  waiting  for  automatic  sterilization  or  effective 
attenuation  of  the  pus  within  the  quiescent  mass,  is  that  active  gonorrheal 
pus  is  by  no  means  harmless.  General  peritonitis  due  to  the  gonococcus  is 
not  so  rare  as  formerly  supposed.  Hunner  and  Harris  collected  eighteen  cases 
supported  by  bacteriologic  proof,  and  seven  of  these  patients  died.  They 
found  also  twenty-one  cases  in  which,  though  bacteriologic  proof  was  lack- 
ing, the  clinical  evidence  indicated  strongly  that  the  peritonitis  was  gonococ- 
cal, and  five  of  these  patients  died.  Again,  peritonitis  is  not  the  only  danger 
from  operation  on  a  quiescent  but  still  active  collection  of  gonorrheal  pus. 
Price  reports  a  case  in  which  such  an  operation  caused  general  dissemination 
of  the  bacteria,  with  involvement  of  the  joints  and  endocardium  and  finally 
death  fifteen  days  after  the  operation.  There  was  no  evidence  of  peritonitis. 
A  number  of  cases  of  general  dissemination  of  the  gonococcus  have  been  re- 
ported. Hunner  cultivated  gonococci  from  the  blood  taken  from  the  arm  of 
a  patient  five  days  after  abdominal  section  for  supposed  gonococcal  perito- 
nitis, and  in  a  fatal  puerperal  case  Harris  and  Dabney  demonstrated  gonococci 
in  the  A-alves  of  the  heart. 

Streptococcic  Class  (Clinical) 

The  distinguishing  characteristics  are  (1)  the  apparent  cause  of  the 
trouble  and  (2)  the  location  of  the  lesion. 

a.  Apparent  cause.    Nearly  all  the  streptococcic  inflammatory  masses  in 


860  PELVIC   INFLAMMATION 

the  pelvis  can  be  traced  to  sepsis  following  labor  or  miscarriage.  In  the 
adult,  streptococci  do  not  spontaneously  penetrate  the  non-puerperal  uterus. 
Aside  from  labor  or  miscarriage,  streptococcus  infection  may  be  due  to  curet- 
ment  or  other  uterine  operation,  to  intrauterine  application  or  sounding,  to 
a  stem  pessary,  to  abnormal  conditions  caused  by  cancer  or  fibroid,  or  chronic 
inflammation.  If  a  pelvic  inflammatory  trouble  can  not  be  traced  to  one  of 
the  causes  above  mentioned,  it  is  almost  certainly  not  streptococcic.  In  tak- 
ing the  history,  care  must  be  exercised  not  to  miss  an  early  miscarriage  or 
an  intrauterine  treatment.  Care  must  be  taken  also  to  trace  the  trouble 
back  to  its  very  beginning,  otherAvise  an  exacerbation  remote  from  the  causal 
miscarriage  or  labor  may  be  mistaken  for  the  beginning  of  the  trouble. 

On  the  other  hand,  not  all  puerperal  cases  are  streptococcic.  About  25 
per  cent  of  puerperal  infections  are  gonococcal.  They  are  usually  of  a  mild 
type  and  subside  quickly,  but  it  must  be  kept  in  mind  also  that  other  puer- 
peral infections  (staphylococcic  and  even  streptococcic)  may  run  a  mild 
course.  Consequently  the  mildness  of  the  preceding  septic  attack  must  not 
be  given  too  much  weight.  Outside  of  external  evidences  of  gonorrhea 
(about  the  vulva  or  in  the  discharge),  most  dependence  is  to  be  placed  on 
the  location  of  the  lesion.  Streptococcus  lesions  are  usually  parametrial, 
while  gonococcus  lesions  are  usually  tubo-ovarian. 

Another  complicating  factor  in  these  puerperal  cases  is  that  there  may  be 
a  mixed  infection,  causing  both  kinds  of  lesions  to  be  present.  Stone  and 
McDonald  reported  such  a  case.  This"  case  furnished  also  a  beautiful  and 
striking  illustration  of  the  fact  that  the  gonococcus  spreads  by  way  of  the 
mucous  membrane  and  the  streptococcus  by  way  of  the  connective  tissue. 
The  gonococci  occupied  the  right  tube  and  extended  thence  into  the  peri- 
toneal cavity,  while  the  streptococci  occupied  the  right  broad  ligament  and 
extended  thence  into  the  peritoneal  cavity,  where  the  two  forms  of  bacteria 
met.  Another  possibility  in  these  puerperal  cases  is  that  the  two  forms  of 
bacteria  may  be  mixed  in  one  lesion — e.g.,  in  a  pyosalpinx.  This  is  evidently 
very  rare,  but  it  has  occurred,  and  the  possibility  of  it  should  make  us  al- 
ways suspicious  of  a  postpuerperal  inflammatory  mass  wherever  located. 
In  such  a  case  the  evidences  for  and  against  the  presence  of  streptococci 
should  be  most  carefully  canvassed  before  deciding  to  subject  the  patient  to 
abdominal  section. 

b.  Location  of  the  lesion.  A  chronic  lesion  in  the  pelvis  of  streptococcic 
origin  is  nearly  always  in  the  connective  tissue  (parametrium).  Unlike  the 
gonococcus,  the  streptococcus  does  not  progress  along  the  mucosa  into  the 
tube,  but  penetrates  the  wall  of  the  uterus  and  extends  into  the  connective 
tissue  (Fig.  697).  It  not  infrequently  extends  from  the  connective  tissue 
to  the  peritoneum,  causing  peritonitis.  Of  course,  in  exceptional  cases  strep- 
tococci may  pass  from  the  uterus  into  the  tube,  but  in  such  cases  they  are 
likely  to  pass  on  through  the  tube  and  cause  fatal  peritonitis.  Consequently, 
in  the  streptococcic  cases  that  survive  the  acute  attack,  and  come  later  for 


TREATMENT    OP    CHRONIC   PELVIC   INPLAMMATION 


861 


treatment  for  an  inflammatory  mass,  the  lesion  nearly  always  involves  the 
connective  tissue  (parametrium).  As  before  mentioned,  Menge  found  the 
streptococcus  in  four  cases  of  pyosalpinx,  while  Whiteside  and  Walton  found 
it  in  three,  but  parametritis  was  not  excluded.  The  last  mentioned  authors 
endeavored  to  produce  streptococcus  salpingitis  experimentally  by  inject- 
ing into  the  uterus  in  rabbits  pure  cultures  of  streptococci  and  also  mixed 
cultures  of  streptococci  and  staphylococci.  In  no  instance  did  salpingitis  re- 
sult. One  rabbit  died  of  acute  streptococcus  septicemia,  while  the  others 
simply  developed  a  purulent  vaginitis  for  a  few  days  and  then  recovered,  and 
when  replaced  in  the  rabbit  pen  became  pregnant  and  bore  litters  of  six  rab- 
bits each.  Miller,  in  the  bacteriologic  examination  of  127  cases  of  pelvic  in- 
flammation, found  the  streptococcus  7  times,  but  in  no  case  was  the  lesion  a 


Fig.  697.  Streptococcal  Infection  in  Uterus  and  Resulting  Lesion.  Streptococcal  inflammation  extends 
through  the  uterine  wall  into  the  connective  tissue  (as  indicated  in  left  side),  forming  a  mass  in  the  broad 
ligament. 


pyosalpinx  alone.     There   are  very  few-  exceptions  to   the  rule   that  strep- 
tococcal masses  in  the  pelvis  are  parametrial  in  whole  or  in  part. 

Are  all  parametrial  inflammatory  masses  streptococcic?  Nearly  all. 
That  parametrial  suppuration  is  usually  due  to  the  streptococcus  is  sub- 
stantiated by  Rosthorn,  Bumm,  Doleris,  and  Bourges,  West,  Cullingworth  and 
others.  Hartman  and  Morax  found  it  in  21  cases  of  parametrial  abscess.  In 
every  such  case  operated  on  by  Fritsch  the  streptococcus  was  found  to  be  the 
cause.  It  is  only  occasionally  that  staphylococci  and  other  bacteria  are  found 
either  alone  or  associated  with  the  streptococcus.  As  parametrial  inflamma- 
tion is  nearly  always  due  to  the  streptococcus,  every  case  presenting  a  para- 


862  PELVIC   INFLAMMATION 

metrial  mass  should  be  placed  in  the  streptococcic  class  until  it  is  definitely 
proved  to  be  due  to  some  other  cause. 

The  distinguishing  characteristics  of  a  parametrical  mass  (chronic)  are: 
fa)  its  situation  in  the  connective  area,  usually  in  the  broad  ligament;  (b) 
its  low  situation  in  relation  to  the  uterus,  often  coming  far  down  beside  the 
cervix;  (c)  its  intimate  blending  with  the  uterine  wall,  as  though  it  Avere 
a  part  of  the  same;  (d)  its  intimate  blending  with  the  pelvic  wall,  as  though 
it  were  an  outgrowth  from  that  structure;  and  (e)  its  hardness,  often  being 
so  hard  as  to  simulate  a  cartilaginous  or  bony  tumor  growing  from  the  pelvic 
wall.  A  tubo-ovarian  mass,  on  the  other  hand,  is  distinguished  by  its  being 
situated  high  in  the  tubo-OA^arian  region,  or  prolapsed  into  the  cul-de-sac; 
by  its  not  blending  so  intimately  with  the  uterine  wall,  a  distinct  groove 
usually  marking  the  point  where  the  two  come  in  contact ;  by  its  not  blending 
so  closely  with  the  pelvic  wall;  by  its  presenting  to  the  examining  finger  a 
portion  of  the  roinicled  outline  of  the  tube  or  ovary;  and  by  absence  of  the 
cartilaginous  hardness  often  seen  in  chronic  parametrial  masses. 

In  the  article  previously  mentioned  the  details  are  given  of  a  series  of  cases 
of  the  streptococcic  class  (clinical),  showing  the  tAvo  principal  diagnostic  points 
before  operation,  the  interval  of  time  from  infection  to  operation,  the  bac- 
teria found  at  operation  and  the  degree  of  virulence  (as  indicated  by  the  re- 
sult of  the  operation). 

From  this  series  of  cases  of  the  streptococcic  class  (clinical)  the  follow- 
ing facts  may  be  adduced : 

Reliability  of  the  Two  Diagnostic  Points  Available  Before  Operation. 
When  the  history  showed  that  the  trouble  originated  from  labor  or  abortion 
and  the  examination  showed  a  well  marked  parametritis,  streptococci  were 
found  in  every  case  except  one.  This  one  exception  (case  16)  was  Hunner's 
case,  and  he  was  not  altogether  satisfied  with  the  bacteriologic  examination, 
but  stated  that  he  regarded  the  ease  as  streptococcal  in  spite  of  the  negative 
findings. 

"When  the  two  points  do  not  agree,  then  the  principal  weight  should  be 
given  to  the  location  of  the  lesion.  But  not  a  sufficient  number  of  carefully 
observed  cases  has  accumulated  to  define  accurately  hoAv  great  dependence 
may  be  placed  on  the  location  of  the  lesion  in  these  uncertain  cases.  This 
is  a  point  to  be  further  investigated.  For  the  present  these  uncertain  cases 
should  be  considered  Avith  great  care  in  order  that  no  streptococcic  case  be 
alloAved  to  slip  into  the  gonococcic   (abdominal  section)   class. 

Persistence  of  Virulence.  The  virulence  of  the  streptococcus  persists 
indefinitely.  Miller  reports  one  case  in  which  the  bacteria  persisted  for  six 
years  and  another  in  which  they  persisted  for  twelve  years.  Martin  states 
that  streptococci  have  been  found  fully  virulent  in  a  pelvic  inflammatory 
mass  after  nineteen  years.  In  one  instance  (case  19)  streptococci  apparently 
disappeared  in  six  months,  but  the  pus  also  disappeared.  The  case  Avas  one 
of  severe  sepsis  folloAving  labor.     On  the  eighth  day  A^^aginal  incision  into  a 


TREATMENT   OF    CHRONIC   PELVIC   INFLAMMATION  863 

pelvic  abscess  evacuated  pus  containing  streptococci.  Six  months  later,  a 
mass  persisting,  a  vaginal  incision  Avas  made  into  the  cul-de-sac  and  the  mass. 
No  pus  was  found,  but  there  was  serous  fluid  showing  staphylococci  alone. 

Automatic  sterilization  of  a  streptococcus  abscess  is  perhaps  possible, 
but  it  is  so  rare  that  it  is  not  to  be  counted  on.  A  streptococcal  mass  in  the 
pelvis  is  always  dangerous,  and  abdominal  section  for  the  same  at  any  time 
is  likely  to  be  followed  by  a  fatal  peritonitis.  The  cases  tabulated  in  the 
article  mentioned  give  striking  proof  of  the  seriousness  of  intraperitoneal 
operation  in  these  cases. 

Character  of  Operation.  The  only  safe  way  to  operate  for  streptococcal 
pus  collections  is  by  the  extraperitoneal  method.  If  possible,  the  pus  collec- 
tion should  be  reached  and  evacuated  per  vaginam.  If  this  can  not  be  accom- 
plished, it  may  be  practicable  to  drain  the  abscess  by  extraperitoneal  opera- 
tion above  Poupart  's  ligament,  as  was  done  in  some  of  the  cases  mentioned. 
Intraperitoneal  operation  in  these  cases  should  be  undertaken  only  when 
the  patient's  life  is  threatened  by  the  severity  of  the  inflammation  and  it  is. 
impossible  to  reach  the  mass  in  a  less  dangerous  way. 

Conclusions 

1.  In  more  than  half  of  the  cases  of  chronic  suppuration  in  the  pelvis  the 
pus  is  sterile  at  the  time  of  operation,  showing  that  sterilization  of  the  in- 
fected focus  takes  place  automatically  within  a  resonable  time  in  the  ma- 
jority of  cases. 

2.  Abdominal  removal  of  the  mass  while  the  bacteria  are  active  and  viru- 
lent results  in  fatal  peritonitis  or  localized  infection  in  many  of  the  cases. 
Abdominal  removal  of  the  mass  after  the  bacteria  are  dead  or  greatly  at- 
tenuated is  almost  never  followed  by  infection,  even  though  there  is  ex- 
tensive escape  of  pus  into  the  pelvis. 

Hence  abdominal  operation  for  a  chronic  inflammatory  mass  in  the  pelvis 
should  not  be  undertaken  before  the  period  of  probable  sterilization,  except 
in  those  rare  cases  in  which,  in  spite  of  palliative  measures,  the  patient's  life 
is  threatened  by  the  severity  of  the  inflammation  and  the  infected  focus  can 
not  be  satisfactorily  drained  extraperitoneally. 

3.  The  time  required  for  the  death  of  the  bacteria  or  effective  attenua- 
tion of  the  same  varies  greatly  in  the  different  cases.  The  persistence  of 
virulence  depends  largely  upon  the  character  of  the  infection.  The  two  in- 
fections concerning  which  definite  information  has  accumulated  as  to  per- 
sistence of  virulence  are  the  gonococcal  and  the  streptococcal. 

In  the  gonococcal  cases  the  bacteria  are  dead  or  attenuated  to  practical 
sterility  within  three  or  four  months  from  the  beginning  of  the  trouble.  In 
such  cases  abdominal  section  may  be  safely  undertaken  after  this  period.  In 
the  streptococcus  cases,  on  the  other  hand,  the  bacteria  live  and  retain  their 
virulence  indefinitely.     In  some  cases  there  seems  to  be  a  diminution  in  the 


864  PELVIC    INFLAMMATION 

virulence,  but  this  is  erratic  and  not  to  be  depended  upon.  Abdominal  sec- 
tion for  a  mass  of  streptococcus  origin  is  never  safe.  Such  an  operation  at 
any  time,  even  years  after  the  infection,  is  liable  to  be  followed  by  fatal 
peritonitis, 

4.  These  two  classes  may  be  distinguished  before  operation  in  most  cases, 
the  distinguishing  characteristics  of  each  being  found  in  the  apparent  cause 
of  the  trouble  and  the  location  of  the  lesion,  as  already  explained  in  detail. 

5.  What  is  the  preferable  time  for  abdominal  operation  for  a  chronic  in- 
flammatory mass  in  the  pelvis'? 

a.  In  a  case  that  is  clearly  gonococcic  (agreement  on  the  two  points — 
the  apparent  cause  of  the  trouble  and  the  location  of  the  lesion)  abdominal 
operation  may  be  considered  safe  after  three  or  four  months  from  the  onset 
of  the  trouble.  If  after  this  time  the  mass  is  a  source  of  serious  irritation  in 
spite  of  palliative  treatment,  it  should  as  a  rule  be  removed.  On  the  other 
hand,  if  there  is  marked  improvement,  it  is  better  to  wait,  as  Nature  may 
bring  about  recovery  without  operation. 

b.  In  a  case  that  is  clearly  streptococcic  (agreement  on  the  two  points) 
abdominal  section  is  never  safe.  Even  where  the  temperature  and  pulse  are 
normal  and  everything  quiescent,  intraperitoneal  operation  for  the  mass  is 
liable  to  cause  the  patient's  death  from  streptococcal  peritonitis. 

c.  In  a  case  that  is  doubtful  (disagreement  on  the  two  points)  a  most 
careful  study  should  be  made  of  all  the  features  of  the  case  and  every  help- 
ful diagnostic  method  shold  be  brought  into  use  to  aid  in  reaching  a  positive 
conclusion.  No  intraperitoneal  operation  should  be  undertaken  until  the 
streptococcus  is  excluded  with  reasonable  certainty.  In  a  doubtful  case  in 
which  the  abdomen  is  opened  on  the  supposition  that  the  mass  is  tubo-ova- 
rian  and  it  is  found  before  adhesions  are  much  disturbed  that  the  mass  is  prin- 
cipally in  the  connective  tissue  (parametritic),  the  route  of  attack  should  be 
changed  to  extraperitoneal  (per  vaginam  or  above  Poupart's  ligament)  and 
the  abdominal  wound  closed.  Such  a  lesion  probably  contains  streptococci 
and  the  adhesions  of  omentum  and  bowel,  which  cause  the  deceptive  mass 
high  in  the  tubal  region,  constitute  Nature's  barrier  between  the  virulent 
bacteria  and  the  peritoneal  cavity.  When  this  barrier  is  broken  down,  the 
way  is  opened  for  a  fatal  peritonitis. 

6.  There  are  three  reasons  for  calling  special  attention  to  this  subject: 
a.  A  matter  of  such  vital  importance  should  be  given  more  prominence  in 
textbooks  and  in  instruction  to  students,  and  in  society  proceedings  and  dis- 
cussions concerning  pus  collections  in  the  pelvis,  b.  Lives  are  still  being 
sacrificed  by  operators  who  seem  unaware  of  the  great  danger  of  abdominal 
operation  for  inflammatory  masses  following  puerperal  sepsis,  c.  Further 
investigation  (with  careful  recording  in  large  series  of  cases  of  the  apparent 
cause  of  the  trouble,  the  location  of  the  lesion,  the  interval- of  time  from  in- 
fection to  operation,  the  bacteriologic  findings,  and  the  result  of  operation) 


TREATMENT   OF    CHRONIC   PELVIC   INFLAMMATION  865 

is  required,  that  the  definite  classification  of  the  cases  before  operation,  as 
above  indicated,  may  be  firmly  established  and  errors  eliminated. 

3.  Avoid  Radical  Operation  in  those  cases  in  which  the  examination  shows 
only  a  somewhat  thickened  and  tender  tube  (catarrhal  salpingitis),  or  a 
slightly  enlarged  and  sensitive  and  perhaps  prolapsed  ovary  (cystic  ovary), 
or  adhesions  "s^ath  some  induration  and  fixation,  but  with  no  distinct  mass. 
Give  a  thorough  trial  to  the  non-operative  measures  previously  mentioned, 
with  such  additions  and  modifications  as  the  peculiarities  of  the  case  may 
suggest.  In  those  cases  in  which  all  signs  of  active  inflammation  have  sub- 
sided, leaving  only  adhesions  binding  the  uterus  or  ovary  in  abnormal  position  or 
distorting  the  tube,  much  benefit  may  sometimes  be  derived  from  pelvic  massage, 
with  stretching  of  adhesions,  or  from  pressure-treatment,  or  from  the  two  in  com- 
bination. In  cases  with  troublesome  uterine  discharge  and  excessive  menstrual 
flow  or  painful  menstruation,  thorough  dilatation  and  curettage  is  advisable. 
This  tends  to  diminish  the  discharge  and  menstrual  suffering,  and  in  some 
cases  it  has  a  decided  beneficial  effect  on  the  adjacent  adnexal  trouble. 
Furthermore,  it  gives  a  chance  for  a  thorough  examination  under  anesthesia, 
by  which  the  exact  condition  of  the  ovaries,  tubes  and  uterus  can  be  more  ac- 
curately determined.  In  cases  with  persistent  pain  without  decided  pal- 
pable lesion — i.e.,  those  eases  in  which  the  nervous  element  is  marked  and  in 
which  the  affection  approaches  the  character  of  a  neuralgia  or  neuritis — 
electricity  may  give  some  relief.  It  is  in  these  cases  also  that  a  tonic  regi- 
men (with  general  massage,  brush  rubs,  salt  rubs,  etc.)  and  antineuralgic 
remedies  are  especially  indicated,  and  often  produce  a  cure  with  little  or  no 
local  treatment. 

Careful  study  should  be  made  of  the  patient  generally — of  all  the  or- 
gans. In  some  such  cases  it  will  be  found  that  the  principal  trouble  is  some 
general  disease  or  some  local  disease  in  another  portion  of  the  body,  the 
pelvic  disorder  being  of  secondary  importance.  If  nothing  is  found  outside 
the  pelvis  to  account  for  the  patient's  symptoms  and  all  other  measures  fail 
to  relieve  the  pelvic  distress,  open  the  abdomen  and  ascertain  the  exact  con- 
dition of  the  pelvic  organs  and  vermiform  appendix  and  then  correct,  as  far 
as  possible,  the  pathologic  conditions  found. 

4.  In  the  operative  cases,  when  the  patient  is  under  forty  years  of  age 
and  the  pathologic  condition  will  permit,  preserve  enough  ovarian  tissue 
to  continue  menstruation  and  enough  Fallopian  tube  to  make  pregnancy  pos- 
sible if  the  organs  do  not  seem  seriously  involved  in  the  inflammatory  process. 
Preservation  of  an  already  diseased  organ  may  necessitate  another  serious 
operation  at  a  later  date. 

In  those  eases  where  all  active  inflammation  has  disappeared,  leaving 
only  adhesions  and  exudate,  it  is  often  possible  to  preserve  in  place  part  of 
an  ovary  and  part  of  a  tuJDe,  which  by  proper  treatment  may  continue  their 
functions. 

This  conservative  work  is  a  comparatively  recent  development  of  pelvic 


866  PELVIC   INFLAMMATION 

surgery,  but  several  cases  of  pregnancy  have  already  been  reported  from 
such  remnants  of  ovary  and  tube  preserved.  Even  if  pregnancy  does  not 
take  place,  the  simple*  fact  that  it  may  take  place— that  it  is  possible— leaves 
the  patient  in  a  much  better  frame  of  mind. 

If  the  uterus  must  be  removed,  one  ovary  at  least  should  be  preserved, 
if  it  is  not  diseased,  because  the  preservation  of  any  ovary,  or  even  part  of 
an  ovary,  tends  to  prevent  those  troublesome  nervous  symptoms  which  fre- 
quently accompany  the  artificial  menopause  and  which  sometimes  become 
serious. 

Prognosis 

What  are  the  ultimate  results  in  cases  of  chronic  pelvic  inflammation? 
What  answer  shall  be  given  to  the  patient  who  asks,  "Doctor,  will  the  pro- 
posed treatment  make  me  a  well  woman?" 

Now,  the  results  differ  much  in  various  cases,  and  in  order  to  answer 
this  question  in  a  comprehensive  way  it  is  necessary  to  divide  the  cases  into 
two  great  classes — the  first  including  those  cases  in  which  the  symptoms  are 
apparently  all  dependent  on  an  evident  lesion,  and  the  second  including  those 
cases  in  which  there  are  symptoms  the  cause  of  which  is  not  clear. 

1.  Where  there  is  a  marked  lesion  in  the  pelvis  of  such  nature  as  to  ac- 
count for  all  the  symptoms  and  the  patient  is  otherwise  in  good  health, 
proper  treatment  will  in  all  probability  effect  a  cure.  The  treatment  must, 
of  course,  be  carried  out  carefully  and  vigorously  according  to  the  indica- 
tions in  the  particular  case.  And  in  any  case  it  will  extend  over  several 
months,  for  even  in  the  cases  in  which  the  pelvic  lesion  can  be  largely  re- 
moved by  operation  the  patient  will  require  careful  after-treatment  to  put 
her  in  good  health. 

As  to  the  promises  you  make  to  the  patient,  be  careful.  You  must  give 
the  patient  all  the  encouragement  possible,  for  encouragement  helps  in  the 
cure,  but  you  must  not  commit  yourself  in  such  a  way  that,  if  something  un- 
foreseen prevents  a  cure,  you  will  be  in  the  position  of  having  promised 
something  that  you  can  not  give.  This  subject  of  prognosis  and  promises  to 
patients  is  one  of  the  most  trying  in  medical  and  surgical  work.  Most  dis- 
eases may,  by  treatment,  be  either  cured  or  improved  so  much  that  the  pa- 
tient thinks  them  cured.  Advertising  quacks  take  advantage  of  this  fact  and 
promise  certain  cure  in  all  cases — "Cure  guaranteed."  Some  of  the  patients 
are,  no  doubt,  really  cured,  and  others  are  so  much  improved  for  the  time 
being  that  they  think  themselves  cured  and  shout  accordingly,  while  those 
who  are  not  improved  are  so  ashamed  of  having  gone  to  a  quack  that  they 
say  nothing  about  it,  and  so  the  impostor  goes  on  without  hindrance.  But 
the  reputable  physician  must  be  careful  with  his  promises.  We  deal  in  facts, 
not  deceptions.  Our  duty  is  to  employ  the  best  possible  means  for  the  relief 
cf  the  patient  and  the  cure  of  her  disease,  and  at  the  same  time  to  give  her 


TREATMENT   OP    CHRONIC   PELVIC   INFLAMMATION  867 

all  the  encouragement  possible.  There  are,  however,  so  many  uncertainties 
that  enter  into  the.  problem  that  it  is,  in  most  cases,  best  to  say  but  little 
about  the  prognosis  unless  the  patient  asks  directly  concerning  it.  If  the 
patient  requests  a  definite  statement  as  to  just  what  chance  she  has  of  perma- 
nent relief,  promise  her  all  that  the  circumstances  will  warrant — giving  the 
most  favorable  construction  to  all  phases — but  always  Avith  this  proviso, 
said  to  the  patient  herself  or  to  a  near  relative,  that  in  spite  of  the  best 
treatment  there  is  a  possibility  of  the  development  of  conditions  which  would 
give  a  different  result.  This  caution  in  promises  is  particularly  important 
in  surgical  work,  for  many  patients  are  prone  to  expect  from  an  operation 
the  cure  of  every  existing  disturbance,  whether  it  comes  within  the  scope  of 
the  operation  or  not. 

2.  In  cases  where  there  is  no  marked  pelvic  lesion,  or  where,  in  addi- 
tion to  a  marked  lesion,  there  are  symptoms  that  are  not  accounted  for  by  the 
pelvic  disease,  the  prognosis  is  uncertain.  The  fact  that  there  are  symptoms 
without  apparent  cause  means  that  there  is  a  hidden  factor  in  the  case,  and 
that  hidden  factor  may  continue  to  cause  much  trouble  after  the  obvious 
lesion  is  removed.  Promise  as  much  as  you  can  count  on  safely,  but  no  more. 
Sometimes  very  serious  or  troublesome  symptoms  will  subside  after  correc- 
tion of  an  apparently  slight  pelvic  disorder.  Many  symptoms,  particularly 
nervous  symptoms,  apparently  not  closely  connected  with  the  pelvic  disease, 
disappear  on  the  cure  of  the  pelvic  disorder,  much  to  the  delight  of  the  pa- 
tient and  of  the  physician.  On  the  other  hand,  many  symptoms,  particularly 
nervous  symptoms,  apparently  due  to  well  marked  pelvic  disease,  persist 
after  the  removal  of  the  disease,  much  to  the  disappointment  of  the  patient 
and  the  physician.  In  some  of  these  cases  the  troublesome  symptoms  had  no 
connection  with  the  pelvic  trouble,  but  were  caused  by  some  entirely  separate 
disorder.  In  other  cases  the  nervous  symptoms  were  really  caused  by  the 
pelvic  disease,  but  through  long  continuance  of  the  irritation  there  was  pro- 
duced in  the  nervous  system  a  pathologic  condition  capable  of  persisting  long 
after  the  removal  of  the  causative  lesion. 

Then,  again,  there  are  certain  cases  of  hereditary  tendency  to  insanity  in 
which  a  serious  pelvic  disease  is  sufficient  to  cause  a  breakdown  and  the  de- 
velopment of  mental  disorder.  In  such  a  case,  though  you  may  hope  for  im- 
provement, you  can  not  promise  much,  for  the  mental  disorder,  once  excited,, 
may  persist  in  spite  of  the  removal  of  the  exciting  cause. 

Again,  occasionally  a  patient  with  this  tendency  to  mental  disturbance 
will  get  along  very  well  until  subjected  to  operation  for  some  disease,  pelvic 
or  otherwise,  and  then  the  added  strain  of  the  operation  upsets  the  mental 
balance  and  she  becomes  insane. 

These  are,  of  course,  exceptional  circumstances,  mentioned  simply  to 
show  how  many  things  the  physician  must  think  of — what  a  broad  vicAv  of 
the  subject  he  must  take — in  giving  a  prognosis  as  to  the  ultimate  result. 


CHAPTER  XI 

OTHER  AFFECTIONS 

of  Fallopian  Tubes,  Pelvic  Peritoneum  and  Pelvic  Connective  Tissue 

PELVIC  TUBERCULOSIS 

Pelvic  tuberculosis  is  tuberculosis  of  the  Fallopian  tubes  or  pelvic  peri- 
toneum or  ovaries,  or  of  all  these  structures  together.  It  is  known  also  as 
''tubercular  salpingitis,"  "tubercular  pelvic  peritonitis"  and  "tubercular 
oophoritis." 

Etiology 

The  same  factors  are  operative  here  as  in  tubercular  lesions  elsewhere; 
namely,  tubercle  bacilli  and  lowered  tissue  resistance.  As  to  how  the  tuber- 
cle bacilli  reach  these  deep-seated  structures,  and  why  they  locate  here,  is 
an  interesting  story  and  one  not  yet  completed. 

The  foUo^^dng  factors  have  a  bearing  on  the  etiology  of  the  affection: 

1.  Tubercular  lesions  in  distant  organs — for  instance,  in  the  lungs. 
From  these  distant  lesions  the  bacilli  get  into  the  blood  stream  and  are  car- 
ried to  various  parts  of  the  body,  frequently  to  the  Fallopian  tubes.  In  some 
eases  the  Fallopian  tube  lesions  constitute  the  only  secondary  lesion  found. 

2.  Tubercular  lesions  in  adjacent  organs,  as  the  bladder,  rectum,  in- 
testines or  abdominal  peritoneum.  The  most  frequent  are  tubercular  ap- 
pendicitis and  tubercular  ulceration  of  the  small  intestine.  In  the  former  the 
process  extends  directly  along  the  peritoneal  surface  to  the  pelvic  peritoneum 
and  the  Fallopian  tubes  and  the  ovaries.  In  the  latter  there  may  be  an  ad- 
hesion between  the  irritated  peritoneal  surface  over  a  tubercular  ulcer  of  the 
intestine  and  the  surface  of  a  tube  or  ovary,  or  of  the  pelvic  peritoneum. 
After  adhesion  the  process  gradually  extends  through  the  intervening  tissue. 

In  tuberculosis  of  the  bladder  or  rectum,  penetration  of  intervening  tis- 
sue may  take  place,  thus  bringing  the  bacilli  in  contact  with  the  structures 
under  consideration. 

3.  Occasionally  the  tubercular  infection  may  come  by  way  of  the  genital 
tract  from  lesions  lower — for  example,  from  tuberculosis  of  the  uterus,  or  of 
the  vagina,  or  of  the  vulva.  This,  however,  is  very  rare,  the  process  usually 
extending  from  above  down^^'ard  instead  of  from  below  upward. 

868 


PELVIC    TUBERCULOSIS 


869 


Pathology 

The  cases  of  pelvic  tuberculosis  may  be  grouped  roughly  into  two 
classes — (A)  those  in  which  the  peritoneum  is  principally  involved  and  (B) 
those  in  which  the  process  is  located  principally  in  one  or  both  Fallopian 
tubes. 


(A)  Peritoneal  Tuberculosis 

Peritoneal  tuberculosis  begins  as  a  deposit  of  fine  tubercles  in  the  pelvic 
peritoneum.  This  deposit  may  take  place  slowly  or  rapidly.  If  it  takes  place 
slowly,  the  disturbance  may  be  slight  and  the  symi3toms  hardly  noticeable. 
If  the  deposit  takes  place  rapidly,  it  produces  the  condition  known  as  acute 
miliary  tuberculosis  of  the  pelvic  peritoneum.  In  this  marked  miliary  form 
the  whole  pelvic  peritoneum  covering  the  various  structures  may  be  closely 
studded  with  the  tubercles  (Fig.  698). 

This  produces  pelvic  peritonitis.  The  peritoneum  about  the  deposits  is 
injected,  reddened  and  lacks  its  normal  luster.  Ascitic  fluid  appears  and  the 
fluid  may  have  a  bloody  tinge.     The  fluid  may  be  free  in  the  peritoneal  cav- 


■'^'l^ 

^t 

i 

M 

I 

^ 

^^^m 

^te 

ll 

^ 

^m 

K^ 

s 

^'"'^m 

^ 

J 

Fig.  698.     Pelvic  Tuberculosis — Peritoneal  Form.      (Kelly — Operative  Gynecology.) 

ity,  with  no  limiting  adhesion,  or  there  may  be  adhesions  that  form  pockets 
in  which  the  fluid  is  confined  (encysted  fluid).  In  this  form  the  tubercular 
process  is  usually  widespread,  involving  a  large  part  of  the  general  peri- 
toneum. The  intestinal  coils  may  be  adherent  to  each  other  or  to  the  parietal 
peritoneum,  or  to  all  the  pelvic  structures.  The  adhesions  are  usually  frail 
and  bleed  easily  upon  being  separated,  but  the  bleeding  soon  stops.  On  ac- 
count of  the  tendency  to  peritoneal  effusion  in  this  miliary  form  of  tuber- 
culosis, the  adhesions  are  not  usually  extensive. 

After  development  to  this  stage  the  tubercles  may  pursue  either  of  two 
courses. 

a.  The  tubercles  may  undergo  fibroid  change.  The  active  symptoms  dis- 
appear, the  fluid  is  absorbed,  and  the  diseased  areas  become  scar-tissue.    This 


870 


PELVIC    TUBERCULOSIS 


is  called  "fibroid  tuberculosis."     It  is  a  limitation  of  the  tubercular  process 
and  constitutes  a  temporary  cure  of  the  disease. 

b.  Instead  of  the  tubercles  passing  into  this  quiescent  condition,  they 
may  spread  and  coalesce  and  break  down,  and  thus  the  process  becomes  pro- 
gressively destructive.  The  tubercular  areas  undergo  necrosis  and  caseation, 
dense  adhesions  take  place,  collections  of  tubercular  pus.  form,  and  all  the 
pelvic  structures  become  bound  together  into  an  irregular  mass,  Avith  broken- 
down  tubercular  lesions  scattered  throughout. 

(B)  Tubal  Tuberculosis 

In  tuberculosis  of  the  Fallopian  tubes  the  process,  instead  of  appearing 
first  in  the  peritoneum,  may  start  in  the  interior  of  a  tube. 


Fig.   699.     Pelvic  Tuberculosis — Tubal  Form.     (Kelly — Operative  Gynecology.) 

In  this  situation  three  forms  are  recognized — (a)  miliary  tuberculosis, 
(b)  chronic  fibroid  tuberculosis  and  (c)  chronic  diffuse  tuberculosis, 

a.  Miliary  tuberculosis  of  a  Fallopian  tube  presents  the  same  character- 
istics as  miliary  tuberculosis  of  other  mucous  membranes — that  is,  there  are 
fine  tubercles  scattered  beneath  the  epithelium  and  not  yet  broken  do-\vn. 
Owing  to  the  structure  of  the  tube,  the  miliary  tubercles  readily  escape  ob- 
servation unless  the  removed  tube  is  examined  microscopically.  This  form 
of  tuberculosis  may  give  rise  to  but  few  symptoms,  and  may  cause  so  little 
disturbance  that  there  is  no  suspicion  of  serious  disease. 


TUBAL    TUBERCULOSIS 


871. 


b.  If  these  tubercles  fail  to  pass  on  to  the  stage  of  caseation,  but  instead 
become  surrounded  by  a  large  amount  of  connective  tissue  and  pass  into  a 
quiescent  state,  we  have  the  condition  kno^\^l  as  "fibroid  tuberculosis  of 
the  tube."  The  tube  is  somewhat  thickened,  and  hardened  and  enlarged  by 
the  infiltration,  but  there  is  little  or  no  breaking  down  of  the  lesions. 

c.  If,  on  the  other  hand,  the  tubercles  progress  to  the  stage  of  caseation 
and  break  down,  there  results  the  condition  known  as  "chronic  diffuse 
tuberculosis  of  the  tubes."  The  tube  is  disorganized  and  contains  a  col- 
lection of  caseous  tubercular  material  (Fig.  699). 

The  appearance  of  the  tube  varies,  of  course,  with  the  severity  of  the 
disease.  In  advanced  cases  the  tube  is  greatly  enlarged  and  on  cutting  it 
open  the  yellow  broken  down  material  is  seen — the  so-called  "caseous  pus." 
This  varies  nmch  in  consistency,  being  in  some  cases  rather  thin  and  in 
others  semisolid.     When  this  is  removed,  the  mucosa  of  the  tube  is  seen  to  be 


Fig.   700.     Tuberculosis   of  a   Fallopian   Tube.      Sev- 
eral typical  giant  cells  may  be  seen. 


Fig.  701.  Tuberculosis  of  a  Fallopian  Tube, 
showing,  under  high  power,  two  giant  cells  from 
the  left   upper  part   of   Fig.    700. 


studded  with  tubercles  in  all  stages  of  breaking  doAvn,  and  there  are  also 
irregular,  ragged  ulcers,  with  small  j'-elloAvish  tubercles  in  their  ^\^alls.  Mi- 
croscopic sections  show  the  characteristic  giant  cells  lying  within  typical 
tubercles,  as  well  shown  in  Figs.  700  and  701. 

When  the  peritoneal  surface  of  the  tube  also  is  involved,  it  is  studded 
Avith  small  tubercles  and  is  usually  adherent  to  some  of  the  surrounding 
organs.     Occasionally  the  tubercular  areas  undergo  calcification.    ■ 

Tubal  tuberculosis  is  also  one  of  the  common  causes  of  general  tubercu- 


872  PELVIC    TUBERCULOSIS 

lous  peritonitis,  a  point  of  importance  which  will  be  further  considered  under 
treatment. 

Pelvic  tuberculosis  has  been  found  to  be  present  in  from  six  to  oight  per 
cent  of  the  eases  of  abdominal  section  for  pelvic  inflammation,  but         ■^r''^^ 
about  a  quarter  of  these  is  it  so  marked  as  to  be  easily  recognized, 
remaining  cases  it  is  recognized   only  by  microscopic   examination 
tions  of  the  tube. 

No  period  of  life  is  exempt  from  genital  tuberculosis.  It  has  beer 
at  all  ages,  from  the  infant  of  a  few  months  to  the  aged  woman  past 
But  the  period  of  life  in  which  it  occurs  most  frequently  is  from  the 
20  to  that  of  40  years ;  i.  e.,  during  the  period  of  greatest  sexual  activit 

Symptoms  and  Diagnosis 

~  The   symptoms   of  pelvic  tubei'culosis   are   much  the   same   as   those 
chronic  pelvic  inflammation.     In  fact  it  is  a  pelvic  inflammation  of  a  sper-'al 
kind.    In  a  large  percentage  of  the  cases  the  diagnosis  of  tuberculosis  i  e 

only  after  the  abdomen  has  been  opened,  the  operation  having  been  ir- 

taken  for  what  was  supposed  to  be  ordinary  pelvic  inflammation. 

In  not  a  few  cases,  however,  a  positive  diagnosis  of  tuberculosis  i' "'t."t>s- 
sible  before  operation,  and  in  some  cases  it  is  easy. 

The  conditions  that  point  to  pelvic  tuberculosis  are  as  follows : 

1.  Symptoms  of  chronic  pelvic  inflammation  in  a  girl  or  young  woman 
who  has  had  no  evidence  of  uterine  infection. 

2.  Gradual  onset  without  previous  uterine  disease,  and  persistent  prog- 
ress without  the  periods  of  marked  improvement  usually  present  in  ordin.^i'y 
pelvic  inflammation.  ^  ^ - 

3.  Emaciation,  gradual  and  persistent,  without  a  corresponding  sev^ 
of  the  inflammatory  trouble. 

4.  Evidences  of  tuberculosis  elsewhere.     Most  cases  of  pelvic  tubi 
losis  occur  in  patients  having  pulmonary  or  intestinal  tuberculosis. 

5.  Tuberculin  reaction.  In  a  doubtful  case  this  may  aid  materian,.-  in 
the  diagnosis.  The  injection  method  or  the  cutaneous  test  may  be  employed. 
The  ophthalmic  test  is  dangerous  to  the  eye  and  had  best  be  avoided. 

Treatment 

If  there  are  no  contraindicating  lesions  elsewhere,  the  affected  tubes 
should  be  extirpated,  preferably  by  abdominal  section.  The  operation  should 
be  preceded  and  followed  by  antitubercular  remedies  and  regimen. 

If  there  are  marked  lesions  elsewhere,  or  if  the  local  trouble  has  ad- 
vanced too  far  for  radical  operation,  employ  palliative  measures.  The  pallia- 
tive measures  include  the  administration  of  antitubercular  remedies  internally, 
the  drainage  of  fluid  collections  by  operation  and  other  measures  mentioned 
under  chronic  pelvic  inflammation. 


EXTRAUTERINE   PREGNANCY  873 

In  some  cases  of  extensive  peritoneal  tuberculosis,  an  apparent  cure  has 
followed  simple  abdominal  section.    It  is  still  a  question  why  such  a  change 
for  the  b-^-tter  should  sometimes  follow  the  mere  opening  of  the  abdomen  in 
+11  "sr         ^s,  but  the  fact  that  such  results  are  secured  has  been  demonstrated 
les,  and  patients  that  are  in  suitable  condition  should  be  given  this 
or  improvement.     The  affected  tubes,  however,  should  always  be  re- 
hen  possible. 

'ic  tuberculosis  often  eventuates  in  general  peritoneal  tuberculosis. 

tubercular  peritonitis  can  usually  be  traced  to  a  tubercular  appendi- 

to  tubercular  salpingitis,  or  to  tubercu:lar  ulceration  of  the  intestine. 

"iating  for  tubercular  peritonitis  it  is  important  to  find  and  remove  the 

'f  it  can  be  done  without  too  much  traumatism.     Mayo  has  done  great 

in  insisting  on  this  and  in  demonstrating  the  marked  increase  in  the 

i      rentage  of  cures  resulting  therefrom. 

-  EXTRAUTERINE  PREGNANCY 

>\  .rauterine  pregnancy  is  pregnancy  outside  of  the  uterine  cavity.  With 
few  •"xeeptions  the  developing  embryo  is,  in  the  beginning,  located  in  the 
Failoj^'ian  tube,  consequently  the  term  ''tubal  pregnancy"  is  applicable  in 
mosi  cases.  The  developing  ovum  may  lodge  in  any  part  of  the  tube  (see 
IPig.  702). 

Etiology 

•  -The  cause  of  extrauterine  pregnancy  is  some  interference  with  the  down- 
u'^id  progress  of  the  fertilized  ovum.     The  o\nim  and  spermatozoa  meet  nor- 

"  in  the  tube,  and  after  fertilization  the  ovum  passes  along  the  remainder 
:  tube  and  into  the  uterus,  where,  having  reached  the  trophoblast  stage, 
it  ?omes  attached  and  develops,  constituting  a  normal  pregnancy.  Now, 
if  tiie.  progress  of  the  fertilized  ovum  is  interfered  with  so  that  it  remains 
in  the  tube  and  develops  up  to  its  trophoblast  stage  there,  extrauterine  preg- 
nancy is  the  result.  This  interference  with  the  dowuAvard  progress  of  the 
o'v  am  is  usually  due  to  some  obstruction  in  the  narrow  proximal  portion  of 
the  tube,  though  the  obstruction  may  be  situated  anywhere  between  the 
ovary  and  the  uterine  cavity.  The  tubal  obstruction  must,  of  course,  not  be 
so  marked  as  to  prevent  the  upward  progress  of  the  spermatozoa ;  conse- 
quently extrauterine  pregnancy  is  impossible  when  both  tubes  are  completely 
occluded  by  inflammation  or  other  process. 

The  conditions  which  interfere  more  or  less  vnth.  the  do"\\aiward  prog- 
ress of  the  ovum  are  as  follows : 

1.  Mild  salpingitis.  Slight  inflammation  may  lead  to  destruction  of  the 
cilia.  The  action  of  the  cilia  is  supposed  to  be  necessary  to  the  normal  prog- 
ress of  the  ovum  from  the  abdominal  to  the  uterine  end  of  the  tube,  the 


874  EXTRAUTERINE    PREGNANCY 

peristaltic  action  of  tlie  tube  being  of  secondary  importance   and  not  suf- 
ficient in  itself  to  carry  the  ovum  along. 

Again,  such  inflammation  leads  to  swelling  of  the  tubal  mucosa  and 
mechanical  obstruction  in  the  narrow  portion  of  the  tube.  This  obstruction, 
while  not  marked  enough  to  prevent  the  upward  progress  of  the  active 
spermatozoa,  may  prevent  the  downward  progress  of  the  passive  ovum. 

2.  Adhesions,  from  inflammation  originating  in  the  tube  or  elsewhere, 
may  so  distort  the  tube  by  bending  or  pressure  as  to  partially  obstruct  its 
lumen. 

3.  Tumors  within  the  tube  wall  or  arising  from  other  structures  may  by 
pressure  narrow  the  lumen  of  the  tube. 

4.  Malformations.  Abel  agrees  with  Freund  that  some  of  the  spiral 
twists  which  are  normally  present  in  the  tube  in  the  embryo  may  persist  to 
adult  life  and  cause  sufficient  obstruction  to  lead  to  extrauterine  pregnancy. 
Diverticula  may  lead  off  from  the  lumen  of  the  Fallopian  tube.  If  a  fertilized 
ovum  lodges  in  one  of  these  blind  canals,  tubal  pregnancy  will  result.  There 
may  be  also  accessory  tubes.  These  are  usually  connected  to  the  normal 
tube,  but  sometimes  by  a  cord  only  without  any  lumen.  In  such  a  ease,  if  a 
fertilized  OA^um  enters  this  accessory  tube,  it  will  remain  there. 

A  rudimentary  tube  which  is  not  open  all  the  way  to  the  uterus  may  be 
entered  by  an  ovum  which  has  been  fertilized  by  a  spermatozoa  passed 
through  the  normal  tube  of  the  opposite  side.  The  large  fertilized  ovum  is 
stopped  at  the  impervious  portion  of  the  deformed  tube,  and  a  tubal  preg- 
nancy is  the  result.  Kelly  illustrates  an  interesting  case  in  which  this  same 
series  of  events  occurred  in  a  rudimentary  uterine  horn,  the  horn  being  so 
separated  from  the  remainder  of  the  uterus  that  it  resembled  part  of  the 
tube  (Fig.  384). 

Pathology 

The  fertilized  ovum  may  lodge  at  any  part  of  the  Fallopian  tube,  as  shown 
in  Fig.  702.  When  the  ovum  becomes  attached  to  the  tube  wall,  certain 
changes  begin.  First,  there  is  marked  hyperemia,  which  leads  to  some  swell- 
ing of  the  structures  and  to  increased  growth  of  all  the  tissue  elements  of 
the  tube  wall.  In  the  mucosa  in  tubal  pregnancy  the  stroma  cells  enlarge 
and  become  decidua  cells,  though  they  do  not  become  so  large  or  so  closely 
packed  together  as  in  the  uterine  mucosa.  There  is  some  hypertrophy  of 
the  muscular  tissue  near  the  attachment  of  the  ovum.  Very  soon  there 
appear  certain  interesting  changes  that  have  a  bearing  on  the  early  rupture 
of  the  pregnant  tube.  As  the  fetal  elements  reach  into  the  tubal  tissues,  seek- 
ing nourishment,  the  wall  of  the  tube  becomes  penetrated  by  cells  of  the  tropho- 
blast  layer.  These  trophoblast  cells  Avork  into  the  muscular  layer  of  the  tube 
and  weaken  it,  and  gradually  penetrate  all  the  way  through  the  wall.     This 


PATHOLOGY  875 

growth  of  fetal  elements  into  and  through  the  wall  of  the  tube  causes  early 
rupture  of  the  tube  and  serious  internal  hemorrhage  (Fig.  711).  . 

Pathologically  and,  in  a  measure,  clinically,  the  cases  may  be  divided 
into  the  following  classes : 

1.  Before  Rupture.  The  developing  embryo  with  its  membranes  is  still 
completely  surrounded  by  the  unbroken  tube  (Fig.  709). 

2.  Intraperitoneal  Rupture  with  Single  Moderate  Hemorrhage.  The  blood 
gravitates  into  the  cul-de-sac  of  Douglas.  Adhesions  bind  together  .the  struc- 
tures above,  thus  forming  a  roof  which  shuts  off  the  blood-filled  cul-de-sac 
from  the  remaining  part  of  the  peritoneal  cavity.  This  condition  is  knoAvn 
as  "pelvic  hematocele"  (Fig.  703).  The  blood  may  be  gradually  absorbed 
without  further  disturbance  or  the  hematocele  may  require  drainage,  as  de- 
scribed under  treatment.     The  very  early  embryo  w^ith  membranes,  having 


Fig.  702.  Diagram  Representing  the  Sites  for  the  Various  Forms  of  Tubal  Pregnancy.  /,  Interstitial 
pregnancy.  2.  Isthmial  pregnancy,  j,  Ampullar  pregnancy.  4,  Infundibular  pregnancy.  5,  Tubo-ovarian 
pregnancy.     (Gilliam — Practical  Gynecology.) 

been   completely   cast   otf  from   its  point   of   nourishment,   perishes,    and   is 
usually  absorbed  without  causing  further  trouble. 

3.  Intraperitoneal  Rupture  with  Repeated  Moderate  Hemorrhage.  The 
membranes  usually  remain  partially  attached  within  the  broken  tube,  and 
hence  the  extruded  embryo  continues  to  groAv,  causing  trouble  later.  The 
first  hemorrhage  leads  to  peritoneal  exudate,  with  resulting  adhesions,  which 
bind  together  adjacent  structures.  Thus  the  blood  mass  and  broken  tube  and 
growing  embryo  are  surrounded  by  a  Avail  of  exudate  and  adherent  intestine. 
This  wall  lessens  the  danger  temporarily.  But  after  a  few  days  or  a  few 
weeks  the  continued  growth  causes  further  rupture  of  the  tube  or  of  the 
other  limiting  tissues,  with  accompanying  fresh  intraperitoneal  hemorrhage 
of  small  or  large  amount.  More  exudate  is  then  thrown  out  about  the  new 
blood  mass,  lessening  the  danger  for  a  time.  This  process  may  be  repeated 
many  times  within  the  course  of  a  few  months,  provided  the  patient  does 
not  in  the  meantime  succumb  to  hemorrhage  or  peritonitis.     Thus  there  is 


876 


EXTRAUTERINE   PREGNANCY 


found  in  this  class  of  cases  a  gradually  increasing  mass  (Fig.  704),  accom- 
panied by  frequent  attacks  of  pelvic  pain  and  marked  soreness.  This  class 
includes  the  majority  of  cases  of  extrauterine  pregnancy  that  come  to  oper- 
ation. Whether  or  not  the  patient's  color  and  pulse  are  much  affected  depends 
upon  the  severity  of  the  hemorrhages.  In  many  cases  the  recurring  pain  and 
soreness  are  the  most  evident  features,  and  at  the  bedside  such  cases  are 
often  mistaken  for  ordinary  pelvic  inflammation. 

4.  Intraperitoneal  Rupture  with  Profuse  Hemorrhage.     There  is  a  free 
rupture   of  the   tube    (Fig.   705),   and   blood  jjours    out  into   the  peritoneal 


Fig.   703.     Pelvic    Hematocele.      Indicating    the    condition   where    there   has    been    a    tubal    abortion    and    the 
blood  from  it  has  gravitated  to  the  cul-de-sac  and  become  surrounded  by  exudate. 


cavity  rapidly  and  in  great  quantity.  It  extends  among  the  intestines  and  in 
some  cases  practically  fills  the  abdominal  cavity,  as  indicated  in  Fig.  706. 
The  patient  at  once  passes  into  a  condition  of  severe  shock.  She  is  blanched, 
almost  pulseless  and,  with  the  air-hunger  and  extreme  pain,  presents  a  most 
distressing  picture.  The  cases  of  this  class  have  been  fittingly  designated 
as  the  ''tragic"  cases.     This  severe  and  persistent  hemorrhage  is  most  likely 


PATHOLOGY 


877 


to  oec'iir  -vAlien  the  develuping  ovum  is  situated  near  the  uterus,  in  that 
portion  of  the  tube  known  as  the  "isthmus."  In  the  vast  majority  of  eases 
the  bleeding  ceases  when  the  patient  passes  into  complete  shock,  which  is 
Nature's  provision  for  checking  the  hemorrhage.  In  exceptional  cases,  how- 
ever, the  patient  does  actually  bleed  to  death,  either  from  the  first  free  flow 
cr  from  a  renewal  of  the  bleeding  due  to  vomiting,  bowel  movement,  sitting 
up  or  other  disturbance  of  the  newly  formed  clot. 

5.  Tubal  Abortion.    If  the  place  of  lodgement  of  the  fertilized  ovum  hap- 


^u:'~i  > 


Fig.  704.  Blood  Mass  about  Tube.  Indicating  the  condition  where  there  has  been  rupture  of  the 
tube,  with  repeated  slight  hemorrhages,  resulting  in  a  large  mass  of  blood  and  exudate,  which  surrounds  the 
tube. 


pens  to  be  near  the  outer  end  of  the  tube  (Fig.  702),  the  resulting  enlargement 
of  the  lumen  of  the  tube  by  the  developing  embryo  opens  the  ends  of  the  tube, 
and  the  embryo  with  its  membranes  is  likely  to  be  extruded  from  the  end  of 
the  tube  into  the  peritoneal  cavity.  This  is  called  "tubal  abortion"  (Figs. 
707,  708).  Tubal  abortion  is  accompanied  with  more  or  less  intraperitoneal 
bleeding  and  gives  rise  to  practically  the  same  symptoms  as  tubal  rupture 


878 


EXTRAUTERINE   PREGNANCY 


except  not  usually  so  severe.  A  considerable  proportion  of  cases  of  supposed 
tubal  rupture  are  really  cases  of  tubal  abortion,  particularly  those  resulting 
in  pelvic  hematocele  or  a  slight  mass  higher  about  the  tube. 

6.  Rupture  Into  Broad  Ligament.    AVhen  the  breal?  in  the  tube  wall  takes 


Fig.   705.     Tubal    Pregnancy,    with    Rupture    into    the    Peritoneal    Cavity.       (Gilliam — Practical    Gynecology.} 


Fig.   706.     Tubal   Pregnancy  with  Intraperitoneal  Rupture,  showing  the  blood  in  the  peritoneal  cavity  among 
the  intestinal   coils.      (Dickinson — American   Textbook  of  Obstetrics.} 

place  lietween  the  layers  of  the  broad  ligament,  the  hemorrhage  is  into  the 
connective  tissue  of  the  pelvis — forming  a  "hematoma,"  as  shown  in  Fig.  712. 
The  hemorrhage  may  h&  moderate,  forming  a  hematoma  in  one  broad  ligament, 
or  it  may  be  severe,  forming  a  hematoma  which  gradually  extends  until  it 


PATHOLOGY 


879 


fills  most  of  the  connective  tissue  space  in  one  or  both  sides  of  the  pelvis.  If 
the  extruded  embryo  continues  to  grow  in  the  broad  ligament,  then  arises 
the  condition  designated  as  "broad  ligament  pregnancy." 

7.  Interstitial  Pregnancy.    When  the  ovum  lodges  and  develops  in  the  in- 
terstitial portion  of  the  tube  (Fig.  702),  the  resulting  condition  is  known  as 


Fig.  707.  Tubal  Pregnancy,  with  abortion 
through  the  abdominal  end  of  the  tube  into  the 
peritoneal  cavity.  The  end  of  the  tube  is  dilated, 
but  the  structures  have  not  yet  been  extruded. 
(Kelly — Operative   Gynecology.) 


Fig.  708.  The  Clots,  Membranes  and  Embryo 
extruded  into  the  peritoneal  cavity  in  the  case  of 
Tubal  Abortion  shown  in  Pig.  707.  (Kelly — Opera- 
tive Gynecology.) 


Fig.  709.  Specimen  of  early  Tubal  Pregnancy.  The  opened  amniotic  cavity  shows  the  small  fetus 
still  in  position.  The  tubal  wall  is  thin,  the  area  between  it  and  amniotic  cavity  representing  chorionic 
tissue  destroyed  by  extravasated  blood. 


''interstitial  pregnancy."  This  is  peculiar  in  that  the  development  takes 
place  within  the  wall  of  the  uterus,  though  outside  the  uterine  cavity  (see 
Fig.  347).  In  this  form  of  tubal  pregnancy,  rupture  of  the  gestation  sac 
usually  does  not  take  place  until  much  later  than  Avith  the  ordinary  form. 


880 


EXTEAUTERINE   PREGNANCY 


Also,  the  rupture  may  in  some  cases  be  into  tlie  uterine  cavity.  Consequently 
there  is  a  possibility  of  this  form  of  tubal  pregnancy  terminating  as  a  normal 
(intrauterine)  pregnancy.  Interstitial  pregnancy  in  the  early  stages  ap- 
proaches in  symptoms  and  signs  very  close  to  normal  pregnancy,  and  hence 
presents  more  difficulties  in  diagnosis  than  a  pregnancy  farther  out  in  the 
tube.  It  is  difficult  and  sometimes  impossible  before  operation  to  distinguish 
between  interstitial  pregnancy  and  pregnancy  in  a  rudimentary  horn  of  the 
uterus  (cornual  pregnancy).  The  latter  is  an  intrauterine  pregnancy  in  an 
abnormally  shaped  uterus  and  does  not  belong  to  the  affection  now  under 
consideration  (extrauterine  pregnancy),  though  it  may  require  the  same 
operative  treatment,  as,  for  example,  in  the  ease  shown  in  Fig.  385. 

8.  Ovarian  Pregnancy.  If  the  developing  ovum  is  found  within  the  ovary, 
it  constitutes  ''ovarian  pregnancy,"  of  which  a  few  Avell-substantiated  cases 
have  been  reported. 


Fig.   710.      Specimen  of  Tubal  Pregnancy  farther  advanced.     Amniotic  sac  opened,  chorionic  tissue  of  normal 

appearance. 


9.  Wandering  Pregnancy.  If  the  pregnancy  is  found  in  the  peritoneal 
cavity  without  any  apparent  connection  with  the  tubes,  or  uterus,  or  ovary, 
it  is  called  a  "wandering  pregnancy,"  after  the  manner  of  designating  fi- 
broids which  have  lost  their  connection  Avith  the  uterus.  Such  a  pregnant 
mass  (fetus  and  surrounding  membranes)  may  be  attached  to  and  receive 
blood  supply  from  various  structures.  In  an  interesting  case  reported  by 
Tuholske  the  placenta  was  attached  to  the  liver,  creating  a  most  serious 
condition.  "Abdominal  pregnancy"  is  a  general  term  which  has  been  used 
to  designate  cases  of  pregnancy  developing  in  the  peritoneal  cavity,  with  or 
without  connection  with  the  tube  or  ovary. 

10.  Extrauterine  Pregnancy  Carried  to  Near  Term.  The  fetus  may  develop 
to  term  or  nearly  so.     The  embryo  and  membranes  remain  attached  to.  the 


PATHOLOGY 


881 


"^r    '' 


Fig.   711.     Section  through  chorionic  area  of  the  wall   of  a  pregnant   tube.      Chorionic   villi  in   right  upper 

corner  of  illustration. 


Fig.   712.     Hematoma.     In  the  left  broad  ligament  is  indicated  a  small  hematoma  from  rupture  of  the  tube. 
In  the  right  broad  ligament  is  indicated  a  much  larger  hematoma. 


882 


EXTRAUTERINE   PREGNANCY 


tube  and  derive  nourishment  there,  and  the  fetus  develops  in  the  peritoneal 
cavity  almost  the  same  as  in  the  uterus.  Again,  the  embryo  and  membranes 
may  be  extruded  entirely  from  the  tube  and  find  attachment  to  some  adjacent 
structure,  from  Avhich  nourishment  is  derived,  or  to  some  distant  structure — 
for  example,  the  liver,  as  in  the  case  above  mentioned.  In  this  class 
of  cases,  if  the  patient  survives  long  enough  and  the  fetus  continues  to 
grow  to  term,  false  labor  pains  come  on  and  the  child  dies,  and  it  then  consti- 
tutes a  foreign  body  in  the  abdomen  (Fig.  398).    This  may  lead  to  peritonitis 


rig.   713.     Mother   and   Child   in   a   case   of   E)xtrauterine    Pregnancy,    operated    on   at   full   term. 
American    Gynecological   and   Obstetrical   Jottrnal.) 


(Cragin- 


and  death  of  the  mother,  or  the  dead  child  may  become  somewhat  encapsulated 
and  remain  for  months  or  years,  constituting  a  ''lithopedion"  (Figs.  399  and 
400  show  such  a  case).  In  rare  instances  of  extrauterine  pregnancy  carried 
to  near  term  the  child  has  been  saved  alive  by  operation.  Fig.  713  shows  the 
child  and  the  mother  in  one  such  case. 


Symptoms  and  Diagnosis 

Before  Rupture.  The  first  rupture  of  the  tube  with  slight  bleeding  takes 
place  within  a  few  weeks  after  the  lodgment  of  the  fertilized  ovum.  Previous 
to  this  primary  rupture  the  symptoms  are  practically  those  of  an  early 
pregnancy.  The  patient  goes  over  her  menstrual  time  without  the  menstrual 
flow  appearing.  There  is  some  nausea,  usually  most  marked  in  the  morn- 
ing, and  perhaps  some  tenderness  of  the  breasts.  Pain  is  not  necessarily 
present.  There  may  be  some  soreness  in  the  pelvis,  either  general  or  localized 
to  one  side,  but  this  is  rarely  troublesome  enough  to  arouse  suspicion  of 
anything  abnormal,  for  some  soreness  through  the  pelvis  is  very  common  in 
normal  pregnancy  owing  to  the  marked  congestion  and  the  enlarging  uterus. 

Pelvic  examination  at  this  stage  shows  some  tenderness  about  the  adnexa 


SYMPTOMS   AXD   DIAGNOSIS  883 

of  one  side,  and  perhaps  a  small  mass,  due  to  the  enlargement  in  the  tube. 
Ho-^vever,  the  normal  ovaries  are  usually  tender,  especially  when  congested, 
as  in  early  pregnancy,  and  the  tenderness  is  frequently  more  marked  on  one 
side.  The  small  mass  in  the  tubal  region  is  really  the  only  positive  evidence 
of  any  abnormal  condition  within  the  pelvis,  and  as  far  as  knoAvn  this  mass  may 
have  been  there  for  a  long  time,  due  to  some  previous  trouble.  Unless  a 
previous  examination  has  shown  the  pelvis  to  be  clear,  making  it  certain 
that  the  little  mass  is  of  recent  development,  the  diagnosis  of  tubal  pregnancy 
is  hardly  justified,  for  there  is  not  sufficient  evidence  to  establish  it.  A  diag- 
nosis based  upon  such  insufficient  evidence  will  prove  erroneous  in  the  great 
majority  of  cases,  as  has  been  amply  demonstrated  by  the  operative  results 
from  such  hasty  diagnoses.  In  exceptional  cases  the  soreness  will  be  so 
well  localized  to  one  side  and  so  marked,  particularly  on  exertion,  and  the 
tenderness  of  the  little  mass  so  very  pronounced  on  palpation,  in  a  ]3atient 
previously  perfectly  well,  that  a  diagnosis  of  tubal  pregnancy  with  operation 
for  the  same  before  rupture  may  be  safely  made.  But  such  cases  are  very 
i-are,  the  conditions  so  closely  simulating  normal  pregnancy  that  no  suspicion 
of  abnormality  is  aroused,  or,  if  aroused,  the  examination  signs  are  not 
positive.  It  .seems  probable  that  a  large  proportion  of  the  cases  set  forth  as 
diagnosed  and  operated  on  ''before  rupture"  are  really  not  seen  until  after 
the  primary  rupture.  There  may  not  be  much  disturbance  from  this  first 
rupture,  only  a  very  slight  hemorrhage  taking  place.  But  this  is  sufficient 
to  give  the  few  sharp  pains,  and  the  persistent  soreness,  and  the  markedly 
tender  mass  without  apparent  cause — the  three  symptoms  that  occupy  such 
an  important  place  in  the  diagnosis  of  tubal  pregnancy  after  rupture. 

Be  careful  (1)  to  make  a  pelvic  examination  in  every  case  of  early  preg- 
nancy in  which  there  is  sufficient  pain  or  soreness  in  the  pelvis  to  arouse 
suspicion  of  some  abnormality,  (2)  to  make  no  positive  diagnosis  of  tubal 
pregnancy  unless  the  physical  signs  justify  it,  and  (3)  to  pronounce  no  case 
"before  rupture"  which  shows  blood  in  the  pelvis,  or  recent  plastic  exudate 
and  adhesions  about  the  tube,  or  damage  to  the  peritoneal  coat  of  the  tube 
at  the  time  of  operation. 

Rupture  with  Repeated  Moderate  Hemorrhages.  In  the  majority  of  cases 
tubal  pregnancy  after  the  primary  rupture  presents  the  symptoms  and  signs 
of  ordniary  acute  or  subacute  pelvic  inflammation  (salpingitis),  but  with 
certain  peculiarities. 

Suppose  that  you  are  called  to  see  a  patient  with  pain  in  the  pelvis  and 
lower  abdomen,  and  a  tender  mass  beside  the  uterus  or  behind  it.  Is  the 
trouble  ordinary  pelvic  inflammation  or  is  it  tul)al  pregancy  with  resulting 
inflammation? 

As  ordinary  pelvic  inflammation,  in  the  form  of  salpingitis,  is  the  more 
common  affection,  it  is  to  be  assumed  that  the  trouble  is  ordinary  pelvic  in- 
Jlammation  and  not  tubal  pregnancy,  unless  there  are  special  symptoms  point- 


884  EXTRAUTERINE   PREGNANCY 

ing  to  the  latter.    The  special  symptoms  pointing  to  tnbal  pregnancy  (but  not 
pathognomonic  of  it)  are  as  follows: 

1.  A  Missed  Menstruation.  The  patient,  previously  regular  in  her  men- 
struation, fails  to  come  unwell  at  the  proper  time.  She  goes  overtime  a  few 
days  or  a  week,  or  several  weeks. 

2.  Sudden  Onset  of  Pain.  After  going  overtime  for  a  few  days  or  a  few 
weeks,  the  patient  is  suddenly  seized  Avith  pain  in  the  pelvis,  usually  severe 
enough  to  confine  her  to  bed,  and  in  exceptional  cases  she  is  completely  pros- 
trated and  in  collapse; 

3.  Bloody  Vaginal  Discharge.  Usually  within  a  few  days  of  the  onset  of  ■ 
the  pain  a  blood-stained  vaginal  discharge  appears.  The  patient  regards 
this  as  the  return  of  the  menstrual  flow.  But  generally  it  is  not  so  free  as  the 
regular  menstrual  flow,  and  does  not  stop  in  a  few  days  as  the  menstrual  flow 
should,  but  persists  as  an  irregular  bloody  discharge  for  a  week  or  two — some 
days  present  and  other  days  absent.  In  some  cases  there  are  shreds  of  mem- 
brane and  blood  clots  in  the  discharge,  leading  to  the  supposition  that  a 
miscarriage  has  taken  place. 

4.  Only  Slig'ht  Fever.  The  temperature  may  go  up  to  102°  or  even  higher 
at  the  onset  of  the  trouble,  but  after  that  it  usually  ranges  about  100°  and 
may  go  to  normal.  The  absence  of  marked  fever  is  one  of  the  strong  points 
in  distinguishing  tubal  pregnancy  from  early  abortion,  with  persistent  bloody 
discharge  and  infection  and  salpingitis. 

5.  Evidence  of  Internal  Hemorrhage.  This  will,  of  course,  vary  with  the 
amount  of  blood  lost  internally.  If  the  internal  hemorrhage  is  free,  the 
patient  may  be  in  collapse,  within  a  few  minutes  after  the  onset  of  the  pain. 
In  other  cases  the  internal  bleeding  is  so  slight  as  to  produce  no  effect  on  the 
patient's  pulse  or  color — but  it  causes  pain. 

6.  Exacerbations  of  Pain  without  Apparent  Cause  and  without  Decided 
Elevation  of  Temperature.  This  is  characteristic  of  those  cases  of  tubal  preg- 
nancy in  which  there  are  repeated  slight  internal  hemorrhages. 

In  salpingitis,  with  the  patient  quiet  in  bed,  such  exacerbations  of  pain 
could  be  caused  only  by  an  increase  in  the  inflammatory  process,  and  this 
would  be  accompanied  by  a  decided  rise  in  temperature. 

7.  Signs  of  Pregnancy.  Some  of  the  early  signs  of  pregnancy  may  be 
present — for  example,  stomach  disturbance,  or  pain  in  the  breasts,  or  soften- 
ing of  the  cervix  uteri.    The  serum  test  of  Abderhalden  may  be  helpful. 

8.  Absence  of  Intrauterine  Pregnancy.  It  may  be  very  difficult  to  deter- 
mine, in  a  given  case,  whether  the  trouble  is  tubal  pregnancy  with  slight 
hemorrhage,  or  an  incomplete  abortion  with  persistent  bleeding  and  mild 
sepsis  and  salpingitis.  In  such  a  doubtful  case  the  uterus  may  be  cleared 
out  with  the  curet  and  the  scrapings  examined.  If  there  has  been  recent 
pregnancy  within  the  uterus,  the  microscopic  examination  of  the  tissues  re- 
moved will  show  chorionic  villi.  If  the  trouble  is  tubal  pregnancy,  there 
will  be  no  fetal  structures  in  the  scrapings. 


SYMPTOMS   AND   DIAGNOSIS  885 

This  procedure  is  somewhat  dangerous,  for,  if  tubal  pregnancy  be  pres- 
ent, a  fresh  hemorrhage  and  a  serious  one  may  be  started  by  the  manipulations. 
Consequently,  curetment  should  be  employed  in  these  doubtful  cases  only 
when  serious  symptoms  make  a  positive  diagnosis  necessary  at  once.  In  such 
a  case  the  operator  should  have  arrangements  made  so  that  immediate  abdo- 
minal section  may  be  carried  out  should  threatening  symptoms  indicating  in- 
ternal hemorrhage  arise  during  the  process  of  curetment. 

Usually  in  tubal  pregnancy  the  internal  hemorrhage  is  not  severe  at  first, 
and  there  may  be  a  number  of  these  slight  hemorrhages  at  intervals  of  a  few 
days  or  a  few  weeks.  The  hemorrhages  are  not  severe  enough  to  affect  the 
patient 's  pulse  appreciably.  They  cause  only  pain  and  the  evidences  of  pelvic 
inflammation.  The  symptoms  and  diagnosis  in  this  class  of  cases  are  well 
shown  by  the  following  typical  case : 

Patient  thirty-seven  years  of  age.  General  health  good.  Had  one  child  seven  years 
ago.  ISTo  pregnancy  since.  Never  had  any  uterine  or  pelvic  trouble.  Menstruation  was 
regular,  every  twenty-seven  days,  until  about  two  months  before  I  saw  her.  The  last  reg- 
ular menstruation  occurred  December  3.  The  flow  was  in  every  way  normal  and  at  the 
right  time.  December  30  was  the  time  for  the  next  flow  to  appear,  but  it  was  missed  en- 
tirely. The  patient  felt  well  and  there  was  no  reason  why  the  menses  should  stop,  aside 
from  pregnancy.  There  was  some  nausea,  the  breasts  began  to  enlarge  and  were  somewhat 
painful,  and  the  patient  supposed  herself  pregnant.  She  felt  well  up  to  January  26. 
That  was  the  day  for  her  menses  to  appear,  supposing  she  had  not  missed.  The  previous 
day  she  had  been  doing  extra  work,  but  slept  well.  In  the  morning  she  arose  and  went 
about  her  usual  household  duties,  feeling  well.  About  S  a.  m.,  while  still  engaged  with  her 
light  work,  she  was  seized  with  a  sudden  severe  pain  in  the  pelvis.  The  pain  was  intense. 
She  managed  to  get  to  the  bed  and  threw  herself  across  the  foot  of  it.  Her  physician 
was  called  and  found  it  necessary  to  give  morphine  and  to  repeat  it.  This,  of  course, 
relieved  her  very  much,  but  still  the  least  change  of  position  increased  the  pain  and  not 
until  evening  could  she  be  moved  enough  to  remove  her  dress  and  arrange  her  in  bed.  Her 
temperature  was  then  102°.  In  questioning  her  later,  I  could  get  no  history  of  shock.  The 
patient  did  not  remember  having  felt  particularly  weak  or  faint  or  nauseated — she  noticed 
only  the  severe  pain. 

Morphine  and  other  preparations  of  opium  were  continued  in  small  doses  occasion- 
ally for  several  days.  Hot  stupes  were  applied  to  the  lower  abdomen  and  frequent  doses 
of  salts  were  given  to  relieve  the  constipation.  The  pain  and  soreness  gradually  became 
less.  The  temperature  varied  from  101°  to  99°.  On  the  third  day  a  bloody  vaginal  dis- 
charge appeared.  This  was  not  like  the  menstrual  flow,  but  was  scanty  and  irregular.  It 
continued  a  few  days  and  then  stopped.  There  were  no  membranes  or  large  clots  noticed. 
In  about  a  week  the  patient  was  feeling  so  much  better  that  she  sat  up  for  an  hour  or  two. 
The  pain  then  reappeared  and  she  was  obliged  to  return  to  bed.  More  or  less  pain  and  sore- 
ness through  the  pelvis  continued,  and  this  time  she  remained  in  bed  ten  days.  There  was  more 
vaginal  discharge,  but  it  was  not  profuse  nor  irritating.  It  was  occasionally  streaked  with 
blood.  After  ten  days  in  bed  she  felt  so  well  that  she  sat  up  in  a  chair  for  a  short  time. 
No  disturbance  following  this,  she  sat  up  the  next  day  a  little  longer.  After  five  days 
she  walked  out  to  the  dining  room  and  helped  about  the  table.  She  had  then  been  free 
from  pain  for  several  days.  The  next  day,  howevei',  the  pain  returned.  It  was  not  severe, 
but  she  remained  in  bed.  The  following  morning  the  pain  was  worse,  and  I  was  then 
called  in  consultation — about   three  weeks  after  the  beginning  of  the  attack.     I  found  the 


886  EXTRAUTERINE   PREGNANCY 

patient  ,  confined  to  her  bed  with  pelvic  pain  and  decided  tenderness  over  all  the  lower 
abdomen.     Good  pulse,  good  color,  temperature  99°. 

On  vaginal  and  bimanual  examination  I  found  marked  tenderness  all  about  the 
uterus.  In  the  right  tubal  region  there  was  a  small  hard  mass  about  the  size  of  the  ovary, 
but  much  harder  and  not  movable.  In  the  left  tubal  region  there  was  a  larger,  softer  mass, 
which  apparently  occupied  nearly  all  the  left  side  of  the  pelvis.  It  was  so  soft  that  the 
borders  were  not  distinct.  Both  masses  were  situated  rather  high,  but  there  was  so  much 
tenderness  that  I  could  not  press  into  the  pelvis  deep  enough  to  satisfactorily  outline  them. 
There  was  apparently  no  exudate  in  the  cul-de-sac  of  Douglas.  There  was  a  slight  vaginal 
discharge  streaked  with  blood. 

Taking  into  consideration  the  history  of  the  case  and  the  findings  on  examination, 
I  made  a  diagnosis  of  tubal  pregnancy,  with  rupture  three  weeks  previously  and  repeated 
slight  hemorrhages  since.  I  could  not  tell  which  tube  the  pregnancy  Avas  in,  for  there  was 
a  tender  mass  on  each  side  of  the  uterus,  so  I  would  not  venture  a  diagnosis  in  that  respect. 
However,  I  was  inclined  to  think  that  the  pregnancy  was  situated  in  the  right  side;  as  that 
mass  was  the  firmer  and  its  outlines  more  distinct. 

1  advised  that  the  patient  be  brought  to  the  city  at  once  for  operation.  You  may 
think  that  rather  risky  advice  for  a  case  of  ruptured  extrauterine  pregnancy.  But  I  was 
satisfied  that  the  focus  of  disturbance  was  well  surrounded  by  plastic  exudate,  and  that  a 
trip  on  the  train  with  the  patient  flat  on  the  stretcher  all  the  time  would  not  be  attended 
with  much  risk,  particularly  in  view  of  the  fact  that  she  had  already  been  up  and  walking 
about.  I  had  gone  to  the  town  prepared,  of  course,  to  do  whatever  was  necessarj^  at  the 
house,  but  I  concluded  that  the  increased  safety  of  the  operation  in  a  hospital  outweighed 
the  danger  of  the  trip.  The  trip  to  the  hospital  caused  no  particular  disturbance.  When  I 
opened  the  abdomen  I  found  blood  clots  and  adhesions  about  the  left  tube.  The  outer  part 
of  the  tube  was  enlarged  to  the  size  of  a  lemon  and  contained  the  fetus  and  membranes 
still  attached.  The  situation  of  the  mass  of  blood  clots  and  exudate  was  rather  unusual. 
It  was  23rincipally  in  front  of  the  uterus,  over  the  bladder.  The  small  mass  in  the  right 
side  had  no  connection  with  the  tubal  pregnancy.  It  was  the  right  ovary  surrounded  and 
bound  down  by  adhesions.  After  the  left  tube  and  ovary  had  been  removed  and  the  mass 
of  blood  clots  cleared  out,  the  right  ovary  was  freed  from  its  adhesions  and  left  in  place. 
The  patient  recovered  without  incident." 

In  this  case  there  Avas  no  evidence  of  sudden  profuse  loss  of  blood,  and 
from  personal  observations  the  author  is  inclined  to  the  opinion  that  this 
holds  good  in  a  large  majority  of  cases  of  extrauterine  pregnancy. 

Rupture  with  Profuse  Hemorrhage.  In  exceptional  cases  there  is  a  sud- 
den loss  of  a  large  amount  of  blood  into  the  peritoneal  cavity.  In  such  a  ease 
the  symptoms  are  striking  and  urgent.  The  patient's  face  is  blanched,  her 
nose  and  forehead  and  fingers  are  cold,  the  pulse  is  rapid  and  weak  and  fail- 
ing, a  cold  sweat  appears  on  the  face,  respiration  is  short  and  labored — and 
over  all  is  the  intense  pain,  which  is  due  to  the  blood  spreading  through  the 
peritoneal  cavity,  and  of  which  the  patient  complains  as  long  as  she  has  suf- 
ficient strength.  These  are  desperate  cases.  This  sudden  profuse  hemor- 
rhage may  appear  with  the  first  attack  of  pain,  or  the  first  hemorrhage  may 
be  slight,  the  severe  hemorrhage  taking  place  after  several  hours  or  several 
days.  The  following  case,  from  the  author's  records,  gives  a  practical  idea 
of  the  clinical  features  of  the  cases  of  this  class : 

*Report   of    Two   Cases    of   Pregnancy   Requiring    Operation,    H.    S.    Crossen,    M.D.,    St.    Louis    Med- 
ical  Review,   August   24,    1901. 


SYMPTOMS   AND   DIAGNOSIS  887 

About  nine  o'clock  one  morning-  I  was  called  by  telephone  to  see  a  woman  who,  the 
message  stated,  was  having  severe  pain  in  the  abdomen.  When  I  reached  the  house  the  pain 
had  diminished  considerably,  but  was  still  very  troublesome.  It  was  diffuse  throughout  the 
lower  abdomen  and  was  accompanied  by  marked  tenderness  over  the  same  region.  The 
abdominal  muscles  were  tense.  Movement  of  the  patient  in  the  bed  or  jarring  of  the  bed 
increased  the  pain.  Patient's  color  was  good.  Temperature  was  99°.  Pulse  was  76,  full 
and  regular.  There  was  a  bloody  vaginal  discharge,  which  had  appeared  the  day  before 
and  which  the  patient  thought  was  her  menstrual  flow  a  few  days  delayed. 

The  history  obtained  was  that  the  patient's  previous  health  had  been  good,  that 
menstruation  had  been  regular  (about  every  28  days)  and  painless.  Nothing  out  of  the 
ordinary  was  noticed  until  one  week  before.  Tt  was  then  her  time  to  come  unwell,  but 
the  flow  did  not  appear.  She  thought  nothing  of  this,  as  she  occasionally  went  a  few  days 
over  time.  She  felt  well  and  there  was  no  nausea  or  other  indication  of  pregnancy.  In 
a  few  days  a  bloody  flow  appeared.  This  was  not  so  free  nor  so  dark  as  the  regular 
monthly  flow.  But  the  patient  supposed  it  to  be  the  menstrual  flow,  and  she  continued  to 
attend  to  her  household  duties  without  discomfort. 

The  morning  I  was  called  she  had  been  superintending  her  household  work  as  usual. 
While  standing  by  a  table  she  was  seized  with  severe  pain  in  the  lower  abdomen.  She  was 
lifted  to  a  chair  and  the  pain  became  less,  and  she  ate  breakfast.  In  an  hour  the  pain  had 
almost  disappeared  and  she  went  upstairs,  and  felt  very  comfortable  while  sitting  reading. 
She  felt  a  desire  to  go  to  stool  and  during  the  bowel  movement  the  pain  returned  with 
increased  severity,  so  that  she  had  to  be  helped  to  her  room. 

"When  I  saw  the  patient,  about  an  hour  later,  she  was  in  good  general  condition,  as 
already  explained,  and  with  no  decided  symptoms  except  the  abdominal  tenderness  and 
pain  on  movement. 

Vaginal  examination  showed  the  uterus  slightly  enlarged  and  softened,  and  the  whole 
interior  of  the  pelvis  very  tender.  The  least  movement  of  the  uterus  caused  pain.  The 
pehic  tenderness  was  so  marked  that  satisfactory  bimanual  examination  was  not  possible. 
No  mass  could  be  felt  to  either  side  of  the  uterus  nor  behind  it.  The  cervix  was  closed. 
The  marked  and  widespread  tenderness  in  the  jjclvis  and  lower  abdomen  showed  there  was 
something  more  serious  than  a  simple  miscarriage,  wliich  patient  had  concluded  was  the 
trouble.  The  sudden  onset  of  intense  pain,  with  complete  absence  of  previous  disturbance  and 
without  fever,  excluded  peritonitis  due  to  inflammation  of  the  tubes  or  appendix.  There 
was  no  evidence  of  intestinal  obstruction,  or  volvulus,  or  intussusception.  The  pain  and 
liA-peresthesia  were  not  due  to  any  drug  habit,  for  the  patient  had  no  such  habit.  The  diag- 
nosis of  extrauterine  pregnancy  was  fairly  clear,  in  spite  of  the  fact  that  no  pelvic  mass 
could  be  located.  I  wished  to  get  the  patient  to  the  hospital  before  operating,  and,  as  the 
first  hemorrhage  had  evidently  been  slight,  I  thought  that  by  keej)ing  her  perfectly  quiet 
for  a  day  or  two  she  could  be  safely  moved.     I  gave  orders  accordingly. 

The  spontaneous  pain  in  the  lower  abdomen  subsided  and  the  tenderness  gradually 
diminished.  By  evening  the  patient  was  comfortable  when  perfectly  quiet.  The  next 
morning  the  patient  was  much  improved  and  was  feeling  comfortable — so  comfortable  that 
she  did  not  consider  herself  very  sick,  and  did  not  take  kindly  to  the  injunction  to  lie 
quiet  in  the  bed  and  on  no  account  to  rise  up.  That  afternoon  the  pain  returned  to  some 
extent,  but  it  was  not  severe,  and  I  saw  nothing  to  indicate  that  the  patient  would  not 
be  in  good  condition  the  next  morning  for  the  trip  to  the  hospital,  where  a  room  had 
already  been  engaged  for  her.  But  near  midnight  I  received  a  message  that  the  severe 
pain  had  returned  and  that  the  patient  was  short  of  breath.  Hurrying  to  the  house,  1 
found  the  patient  in  collapse.  The  pulse  was  small  and  rapid,  the  features  were  blanched 
and  pinched — the  greatest  possible  contrast  to  the  rosy,  robust  appearance  which  she  pre- 
sented a  few  hours  before.  The  extremities  were  cold,  and  a  cold  perspiration  stood  out  on 
the  face.     Dyspnea  wys  present,  but  the  x^atient   complained  only  of  the  intense  abdominal 


EXTRAUTERINE   PREGNANCY 

pain,  which  seemed  to  be  increasing.  The  hemorrhage  was  still  going  on,  as  evidenced  by 
the  increasing  widespread  pain  and  the  continued  failing  of  the  pulse.  By  the  time  the 
hasty  preparations  for  the  necessary  operation  were  completed,  the  pulse  was  thready  and 
at  times  scarcely  perceptible.  The  patient  told  me  afterwards  that  she  believed  she  was 
dying,  as  she  could  feel  the  chill  on  the  extremities  creeping  closer  and  closer  towards  the 
trunk. 

When  preparations  were  completed,  the  patient  was  etherized  and  the  abdomen  opened. 
The  peritoneal  cavity  was  full  of  blood.  The  ruptured  tube  was  quickly  located  by  touch 
and  clamped.  That  stopped  the  bleeding  temporarily.  The  principal  part  of  the  blood 
was  then  cleared  out  of  the  abdomen,  the  affected  adnexa  removed,  the  peritoneal  cavity 
flooded  with  hot  normal  saline  solution  and  the  abdomen  closed.  The  patient  was  almost 
pulseless  and  continued  in  that  condition  for  40  hours  in  spite  of  all  stimulating  means. 
Good  reaction  then  gradually  came  on  and  the  patient  improved  rapidly  and  made  a  per- 
fect recovery.  Subsequently  she  informed  me  that  late  in  the  afternoon  before  the  nearly- 
fatal  hemorrhage  she  was  feeling  so  well  that  she  sat  up  in  bed  to  take  nourishment  and 
to  chat  with  friends,  regarding  my  strict  admonition  to  keep  perfectly  quiet  on  her  back  as 
' '  overcautious. ' ' 

Differential  Diagnosis 

This  subject  is  of  interest  to  every  one  called  to  make  a  diagnosis  in  acute 
abdominal  affections,  for  in  many  cases  diagnosticated  and  operated  on  as 
tubal  pregnancy  the  operation  revealed  that  the  trouble  was  not  tubal  preg- 
nancy, but  some  entirely  different  affection.  There  are  many  conditions  that 
may  simulate  one  or  more  of  the  principal  symptoms  of  extrauterine  preg- 
nancy, and  these  must  be  taken  into  consideration  in  the  differential  diagnosis. 

The  cardinal  symptoms  of  early  tubal  pregnancy  are  (1)  a  missed  men- 
struation, (2)  sudden  onset  of  pain  (with  or  without  shock),  (3)  bloody  vag- 
inal discharge,  (4)  a  tender  mass  beside  the  uterus,  (5)  only  slight  fever,  and 
(6)  exacerbations  of  the  pain  and  enlargement  of  the  mass  without  corre^ 
sponding  elevation  of  temperature.  In  atypical  cases  there  may  be  decided 
fever  or  onset  of  pains  without  missed  menstruation  or  other  variations  from 
the  rule.  Again,  the  internal  hemorrhage  may  be  very  severe  at  first  requir- 
ing a  diagnosis  at  once  before  the  appearance  of  later  confirmatory  evidences. 
It  may  be  impossible  to  feel  a  mass,  for  the  liquid  blood  itself  gives  no  well- 
marked  resistance  and  yet  causes  so  much  tenderness  that  the  enlarged  tube 
can  not  be  satisfactorily  palpated.  Freshly  coagulated  blood  gives  a  boggi- 
ness,  but  not  a  distinctly  outlined  mass.  After  a  short  time  there  develops  a 
distinct  mass,  due  to  the  fibrin  and  adhesions  and  infiltration  associated  with 
the  blood  clot. 

The  difficulties  of  differentiation  are  due  largely  to  the  fact  that  many 
cases  of  extrauterine  pregnancy  are  atypical  in  symptomatology — presenting 
some  of  the  prominent  symptoms,  but  lacking  others.  Now,  there  are  other 
affections  that  may  present  two  or  three  of  the  prominent  symptoms  of  tubal 
gestation,  and  if  the  distinguishing  characteristics  of  the  other  affection  hap- 
pen to  be  absent  or  obscured  a  mistake  in  diagnosis  is  probable.  Space  will 
not  permit  consideration  of  all  the  conditions  that  may  simulate  tubal  preg- 


CONDITIONS   SIMULATING    TUBAL   PREGNANCY  889 

nancy;  only  a  few  of  the  more  common  ones  may  be  discussed.  These  may  be 
grouped  into  two  classes — first,  those  conditions  in  which  the  principal  feature 
is  a  tender  pelvic  mass,  associated  with  some  of  the  other  symptoms  of  tubal 
pregnancy,  and,  second,  those  conditions  in  which  the  principal  feature  is 
sudden  abdominal  pain  and  collapse  without  apparent  cause;  i.  e.,  without  the 
disturbances  that  usually  precede  or  accompany  collapse  from  other  diseases. 
These  two  main  groups  may  be  further  divided  into  subgroups.  It  is  the  writer's 
object  here  to  put  the  reader  in  practical  touch  with  the  more  common  con- 
ditions that  may  simulate  tubal  pregnancy,  that  he  may  be  on  guard  against 
them  and  thus  avoid  mistakes.  The  most  satisfatory  way  to  do  this  is  to  give 
actual  examples — i.  e.,  to  describe  the  conditions  present  in  cases  that  have 
actually  simulated  tubal  pregnancy  so  closely  that  they  were  mistaken  for  it. 
In  each  of  the  following  cases  the  symptoms  were  so  deceptive  that  they 
caused  a  mistake  in  diagnosis.  There  is  space  for  only  one  example  under 
each  of  the  deceptive  conditions.  Many  other  examples,  with  references,  are 
given  in  an  article*  on  the  subject. 

A  Tender  Pelvic  Mass  with  Other  Symptoms  of  Tubal  Pregnancy 

Gonorrheal  Salpingitis.  With  no  other  disease  does  one  experience  so 
much  difficulty  in  differentiation  from  early  tubal  pregnancy  as  with  salpingitis 
of  gonorrheal  origin.  Typical  cases  of  salpingitis  are,  of  course,  easily  dis- 
tinguished from  typical  cases  of  tubal  pregnancy.  The  difficulty  lies  in  the 
fact  that  either  may  be  atypical,  and  as  they  become  atypical  they  may 
approach  each  other  until  their  manifestations  are  practically  alike — that  is, 
gonorrheal  salpingitis  (atypical)  may  produce  the  symptoms  and  signs  of 
tubal  pregnancy  (slightly  atypical).  Such  cases  are  not  very  frequent,  but 
they  are  encountered  occasionally  in  the  examination  of  a  large  number  of 
cases  of  supposed  extrauterine  pregnancy,  and  when  encountered  they  prove 
most  deceptive  and  misleading. 

Chronic  Gonorrheal  Salpingitis.  Patient,  aged  32.  Last  normal  menstruation  Au- 
gust 10.  In  September  went  over  time  ten  days.  Felt  as  well  as  usual  and  supposed 
herself  pregnant.  No  stomach  disturbance  or  breast  pains.  About  September  20  had  a 
scanty  flow  for  two  days.  She  felt-  well  and  there  was  no  further  bloody  discharge  for  two 
weeks,  when  it  started  again.  A  day  later  she  was  seized  with  severe  pains  extending  all 
through  the  lower  abdomen.  No  shock,  just  pain,  at  times  cramp-like.  This  pain  contin- 
ued oft"  and  on  for  a  week.  Patient  was  confined  to  bed  and  had  to  be  given  morphine. 
A  physician  was  called  and  made  a  diagnosis  of  abortion.  No  membranes  passed  and  there 
was  only  one  small  clot.  Patient  was  then  curetted,  but  not  much  was  obtained — appar- 
ently only  some  thickened  endometrium.  No  fetus  or  membranes  or  shreds  of  tissue  were 
seen  at  any  time.  Patient  felt  better  after  the  curetment,  but  still  continued  sick,  confined 
to  bed  with  abdominal  pain  and  tenderness.  Temperature  99°  to  100°.  Twelve  days  later, 
as  there  was  no  material  improvement,  the  uterus  was   curetted  again,  but  without  result. 


*Conditions  Simulating  Tubal  Pregnancy,  H.  S.  Crossen,  M.D.  Read  in  the  Section  on  Obstet- 
rics and  Diseases  of  Women  of  the  American  Medical  Association,  at  the  Sixtieth  Annual  Session,  held 
at  Atlantic  City,  June,  1909,  Jour.  Am.   Med.   Assn.,   Vol.   LIV,   p.   519. 


890  EXTRAUTERINE   PREGNANCY 

The  trouble  continuing,  a  physician  was  called  in  consultation.  The  abdominal  pains  and 
tenderness  continued  and  the  temperature  then  (after  the  second  curetment)  ranged  from 
100°  to  101".  Six  days  after  the  second  curetment  the  patient  was  brought  to  St.  Louis 
and  placed  under  my  care. 

Examination.  This  showed  the  uterus  retrodisplaced  and  fixed,  and  blended  with  a 
tender  mass  of  adnexal  origin  extending  into  both  sides  of  the  pelvis.  The  average  tem- 
perature was  100";  pulse,  98;  respiration,  20.  Tlie  lowest  temperature  was  99.2°  and  the 
highest  100.6°. 

Diagnosis.  There  was  evidently  serious  adnexal  trouble  of  apparently  recent  origin, 
and  any  one  of  the  following  conditions  was  possible:  (1)  salpingitis  following  miscar- 
riage, (2)  an  acute  exacerbation  of  a  chronic  salpingitis,  and  (3)  tubal  pregnancy  with 
repeated  slight  hemorrhages.  Against  the  first  were  the  low  temperature  (much  lower  than 
consistent  with  an  acute  infection  of  sufficient  severity  to  cause  the  symptoms)  and  the 
absence  of  evidences  of  miscarriage.  Against  the  second  were  the  low  temperature  with 
acute  symptoms,  no  history  of  preceding  severe  symptoms  indicating  old  suppuration  in 
the  pelvis  (though  there  had  been  mild  pelvic  distress  for  some  years)  and  the  association 
of  the  trouble  with  missed  menstruation,  followed, by  sudden  onset  of  pain  and  the  appear- 
ance of  an  irregular  bloody  vaginal  discharge.  If  due  to  an  old  inflammatory  trouble,  one 
would  expect  the  menstrual  flow  to  be  increased  instead  of  missed,  and  the  pain  and  other 
symptoms  to  be  of  rather  gradual  onset  and  increasing  in  severity  as  fluctuation  appeared 
in  the  mass.  In  favor  of  the  third  (tubal  pregnancy)  were  missed  menstruation  followed 
by  sudden  onset  of  pain,  irregular  bloody  discharge,  absence  of  positive  evidence  of  a  mis- 
carriage, and  the  presence  of  fluctuation  in  the  mass,  associated  with  low  temperature 
(much  lower  than  was  consistent  with  a  pocket  of  pus).  It  seemed  a  fairly  clear  case  of 
tubal  pregnancy — one  of  the  class  frequently  met,  in  which  there  is  no  great  loss  of 
blood  at  one  time,  but  re^Deated  slight  hemorrhages  with  a  gradually  increasing  mass.  Ac- 
cordingly that  diagnosis  was  made. 

Operation.  On  opening  the  abdomen  no  tubal  pregnancy  w^as  found.  The  trouble 
was  chronic  adnexal  inflanmiation — there  being  a  tubo-ovariaii  abscess  on  the  left  side, 
which  gave  the  fluctuation,  and  chronic  salpingitis  on  the  right  side,  the  remaining  part 
of  the  mass  being  formed  by  adhesions  and  exudate.  The  damaged  adnexa  and  the  chron- 
ically inflamed  appendix  were  removed  and  the  uterus  fastened  forward. 

The  patient  made  a  pi'ompt  recovery  with  complete  relief. 

Careful  bacteriologic  investigation  of  the  removed  adnexa  showed  no  bacteria  of  any 
kind.  This  excluded  recent  infection.  The  case  was  evidently  one  in  which  there  was  a 
gonorrheal  infection  long  ago  (there  were  confirmatory  facts  in  the  history),  the  develop- 
ment of  pyosalpinx  with  only  slight  symptoms  of  a  mild  character,  the  death  of  the  bacteria 
(which  commonly  takes  place  in  gonorrheal  pyosalpinx),  and  the  persistence  of  sterile  pus 
in  a  sac  which  acted  as  an  irritating  foreign  body  in  the  pelvis.  No  evidence  of  pregnancy 
was  found.  Why  the  menstruation  was  missed  I  can  not  say.  In  some  other  cases  of 
gonorrheal   salpingitis   I   have   encountered   this   misleading   symptom. 

Acute  Double  Salpingitis.  Patient,  aged  19.  About  two  weeks  after  marriage  she 
failed  to  come  unwell  properly.  At  the  menstrual  time  there  was  a  slight  bloody  discharge, 
but  not  a  good  menstrual  flow.  There  was  some  soreness  and  pain  in  the  pelvis.  After 
this  had  continued  a  few  days  she  was  seized  with  sudden  severe  pain  in  the  lower  abdo- 
men, accompanied  by  shock.  With  the  weakness  and  f aintness  and  pain  she  could  hardly 
move,  even  to  turn  over  in  bed,  for  several  houis.  The  severe  pain  gradually  subsided,  but 
marked  soreness  remained,  so  much  so  that  the  patient  was  obliged  to  lie  very  quiet.  A 
physician  who  was  called  examined  the  patient  and  said  that  she  was  having  a  miscarriage. 
A  partial  curetment  was  carried  out,  but  only  a  small  amount  of  blood  was  removed.  No 
fetus,  membranes  or  large  clot  was  passed  at  any  time.     The  patient  and  her  husband  then 


CONDITIONS  si:mulating  tubal  pregnancy  891 

became  uneasy  at  tlie  apj)areiit  seriousness  of  the  troulDle  and  the  day  after  the  curetment 
called  a  physician,  who  asked  me  to  see  the  patient. 

Examination.  The  patient  was  confined  to  bed  with  pain  in  the  lower  abdomen  and 
a  bloody  vaginal  discharge.  There  was  marked  tenderness  on  abdominal  and  bimanual 
examination,  and  there  was  a  boggy  induration  on  each  side  of  the  uterus  with  marked 
tenderness.  Xo  membranes  or  shreds  were  found  in  tlie  cervix  or  in  tlie  bloody  discharge. 
The  discharge  was  blood  and  mucus,  without  noticeable  pus  admixture.  The  trouble  seemed 
to  be  around  the  uterus  rather  than  in  it.  The  temperature  was  low,  fluctuating  between 
100^  and  101°.  Here  was  a  patient,  apparently  previously  healthy,  seized  with  a  severe 
abdominal  pain  and  decided  shock,  associated  with  imperfect  menstruation,  an  irregular 
bloody  discharge,  a  tender  mass  partially  surrounding  the  uterus,  and  low  temperature.  I 
made  a  tentative  diagnosis  of  tubal  pregnancy  with  some  internal  hemorrhage,  but,  not 
being  entirely  satisfied,  I  concluded  to  watch  the  case  for  a  while. 

Under  mild  sedatives  and  strict  confinement  to  bed  the  patient  became  very  com- 
fortable. The  temperature  ran  about  100°.  After  a  few  days  she  felt  so  much  better  that, 
without  my  permission,  she  began  to  go  to  the  washstaud.  On  one  of  these  trips  across 
the  room  she  was  seized  with  pain  and  almost  fainted  before  she  could  reach  the  bed. 
There  was  then  more  pain  and  pelvic  soreness  and  an  increase  in  the  tender  mass  about 
the  uterus.  I  then  insisted  on  the  patient's  removal  to  the  hospital,  where  she  was  kept 
under  observation  for  five  days  longer.  On  admission  the  temperature  was  101.2° ;  pulse, 
100;  respiration,  24.  There  was  considerable  abdominal  pain,  requiring  a  sedative  occa- 
sionally. The  next  day  the  temperature  was  99°  and  for  four  days  did  not  go  above  99.6°. 
In  the  meantime  the  patient  felt  comfortable,  could  sleep  well,  her  appetite  returned,  and 
the  pelvic  soreness  diminished.  The  bloody  discharge  continued.  The  fifth  day,  without 
apparent  cause,  the  abdominal  pain  returned  and  became  very  severe.  The  pulse  rose  to 
132;  temperature,  100.6°;  respiration,  24.  On  examination  the  tender  pelvic  mass  was 
found  to  -be  larger.  The  tentative  diagnosis  of  tubal  pregnancy  seemed  confirmed  by  the 
spontaneous  recurrence  of  severe  pain,  the  rapid  joulse,  and  the  continued  enlargement  of 
the  peh-ic  mass  with  low  temperature. 

Operation.  "When  I  opened  the  abdomen  I  found  there  was  no  extrauterine  preg- 
nancy, but  instead  an  acute  double  salpingitis,  with  leakage  of  pus  into  the  peritoneal 
cavity  and  the  formation  of  extensive  adhesions.  The  tubes  were  so  badly  damaged  that  I 
thought  best  to  excise  them.  After  establishing  free  drainage  of  the  infected  area,  I 
explored  the  interior  of  the  uterus,  thinking  that  possibly  there  had  been  a  miscarriage 
after  all,  WT.th  infection  following  it ;   but  no  evidence  of  pregnancy  was  found. 

The  patient  recovered  without  particular  incident. 

Examination  of  the  pus  from  the  tubes  showed  gonococci  in  abundance  and  in  pure 
cultures.  The  case  was  one  of  gonorrheal  infection  following  marriage,  the  infection  af- 
fecting the  vagina  but  slightly  and  passing  rapidly  up  into  the  uterus  and  tubes  and  out 
into  the  peritoneal  cavity.  A  striking  fact,  and  perhaps  the  most  misleading  one  in  this 
particular  case,  was  the  absence  of  the  usual  evidences  of  acute  gonorrheal  vaginitis 
(burning  on  urination,  vaginal  tenderness,  and  free  puiailent  discharge).  These  were  so 
slightly  marked  that  there  was  no  suggestion  of  the  trouble  being  acute  gonorrhea.  The 
purulent  character  of  the  discharge  was  obscured  by  the  blood  in  it.  Had  I  examined  the 
discharge   microscopically,   gonorrhea  would  at  once  have   been   evident. 

It  may  he  thoiioht  that  some  fever  is  enough  to  exclude  tubal  pregnancy 
as  the  causative  factor,  but  such  is  not  true,  for  in  many  eases  of  extrauterine 
pregnancy  with  hemorrhage  the  temperature  will  run  up  temporarily  to  102° 
and  higher.  The  following  is  a  case  in  point:  Mrs.  P.,  aged  31,  admitted 
to  the  C4ynecologic  Department  of  Washington  University  Hospital.     On  ad- 


892  EXTEAUTERINE   PREGNANCY 

mission  her  temperature  was  101.4°  and  pnlse  140.  She  gave  a  clear  and  typi- 
cal history,  and  the  diagnosis  of  ruptured  tubal  pregnancy  was  positive.  The 
hemorrhage  had  been  so  severe,  however,  that  she  was  in  very  poor  condi- 
tion for  operation.  The  hemoglobin  had  been  reduced  to  30  per  cent,  which 
made  operation  or  even  anesthesia  alone  very  dangerous.  As  the  hemorrhage 
had  stopped  and  she  was  improving,  it  was  decided  to  defer  operation  until 
it  could  be  carried  out  with  less  danger.  The  waiting  period  was  seven  days. 
During  that  time  the  temperature  went  up  to  102°  nearly  every  day  and  one 
day  reached  103.4°.  After  seven  days  the  blood  condition  has  improved 
(hemoglobin  above  40  per  cent)  and  she  was  so  much  improved  otherwise 
that  operation  was  carried  out.  There  was  no  pus  in  the  peritoneal  cavity — 
simply  the  unabsorbed  blood.     The  patient  recovered  promptly. 

Miscarriage  with  Abnormalities.  Various  conditions  associated  with  mis- 
carriage may  lead  to  a  mistaken  diagnosis  of  tubal  pregnancy — for  example, 
an  old  inflammatory  mass  or  a  tumor. 

Miscarriage  and  Ovarian  Tumor.  Eeported  by  Brown.  A  patient  who  had  missed 
the  menstruation  for  three  weeks,  and  had  all  the  symptoms  of  pregnancy,  was  attacked 
with  pains  through  the  lower  abdomen.  A  physician  was  called  and  found  the  patient 
confined  to  bed,  with  abdominal  pain,  partial  suppression  of  urine,  temperature  of  102.5°, 
and  evidently  severe  inflammation  from  some  cause. 

Examination.  The  uterus  was  found  pushed  back  by  a  large  mass  in  the  right 
side  of  the  pelvis.  The  physician  watched  the  case  for  four  or  five  days,  and  felt  con- 
fident that  the  trouble  was  tubal  pregnancy,  with  rupture,  hemorrhage,  and  resulting  in- 
flammation.    Dr.  Brown,  who  was  asked  to  see  the  case,  made  the  same  diagnosis. 

Operation.  This  revealed  an  ovarian  cyst  and  general  peritonitis.  Exploration  of 
the  interior  of  the  uterus  showed  that  there  had  been  a  recent  abortion.  The  miscarriage 
was  evidently  the  cause  of  the  peritonitis,  which  eventually  proved  fatal. 

Miscarriage  and.  Broad  Ligament  Tumor.  Reported  by  Fortun.  This  case  presented 
practically  the  same  features  as  the  preceding  one — namely,  missed  menses,  abdominal 
pain,  bloody  discharge  and  a  tender  mass  beside  the  uterus.  Diagnosis,  extrauterine  preg- 
nancy. Operation  demonstrated  that  the  symptoms  were  due  to  a  tumor  (sarcoma)  of  the 
broad  ligament,  associated  with  an  abortion. 

Pregnancy  with  Abnormalities.  There  are  various  anomalous  condi- 
tions that  may  cause  an  intrauterine  pregnancy  to  simulate  an  extrauterine 
pregnancy. 

Pregnancy  with  Hydatidiform  Mole.  Mrs.  S.,  aged  21,  came  into  my  service  at  the 
St.  Louis  MuUanphy  Hospital  with  a  diagnosis  of  extrauterine  pregnancy.  There  had 
been  no  menstruation  for  two  months,  and  there  were  the  usual  symptoms  of  early  preg- 
nancy. Recently  the  patient  had  been  having  attacks  of  pain  in  the  lower  abdomen,  ac- 
companied by  a  bloody  discharge.  These  attacks  of  pain  had  been  irregular — at  times 
severe  and  confining  her  to  bed,  while  at  other  times  she  was  able  to  be  about  the  house. 
Finally  they  became  so  disabling  that  she  was  brought  to  the  hospital. 

Examination.  When  I  saw  her  she  was  confined  to  bed,  with  a  mass  the  size  of  an 
orange  pushing  forward  the  anterior  abdominal  wall  just  above  the  pubes.  The  mass  was 
firm,  painful  on  pressure,  partially  fixed,  and  it  was  here  that  the  patient  located  the  pain 
and  distress.     There  was  a  bloody  vaginal   discharge.     Temperature,  pulse   and  respiration 


CONDITIONS   SIMULATING   TUBAL  PREGNANCY  893 

were  practically  normal.  On  bimanual  examination,  tlie  deeper  portion  of  the  mass  could 
be  made  out,  and  it  was  found  to  be  the  size  of  a  child's  head.  Indistinct  fluctuation  was 
obtained.  The  body  of  the  uterus  could  not  be  made  out,  but  the  impression  obtained  was 
that  the  mass  lay  in  front  of  the  corpus  uteri,  which  was  pushed  backward  and  could  not  be 
felt  on  account  of  the  mass.  The  forward  projection  of  the  mass  against  the  abdominal 
wall  was  very  marked. 

I  was  inclined  to  agree  with  the  diagnosis  of  extrauterine  pregnancy,  but  was  not 
entirely  satisfied,  as  I  had  not  located  certainly  the  body  of  the  uterus.  I  concluded  to 
watch  the  case  for  a  while.  The  patient  was  kept  absolutely  quiet  and  sedatives  were 
given  as  needed  for  the  pain.  The  patient  was  better  for  a  time,  but  later  the  pain  re- 
curred. It  troubled  her  every  day,  at  times  quite  severely,  but  could  not  be  identified 
as  uterine  contraction  pains.  No  variation  in  the  consistency  of  the  mass  was  noticed. 
The  bloody  discharge  continued.  A  few  very  small  clots  were  noticed,  but  no  membranes 
or  shreds.  I  continued  the  observation  for  ten  days,  and  the  longer  I  observed  the  more 
confusing  the  conditions  became.  The  process,  whatever  it  was,  was  progressing  rather 
rapidly.  In  the  ten  days  the  mass  had  enlarged  decidedly  and  the  pain  had  increased — 
so  much  so  that  at  the  end  of  the  period  it  was  evident  that  something  must  be  done,  as 
further  prolongation  of  the  trouble  would  seriously  weaken  the  patient,  who  was  not  very 
strong  at  the  beginning.  The  crucial  point,  which  so  far  I  had  been  unable  to  decide, 
was  whether  the  mass  was  uterine  or  extrauterine. 

Operation.  I  decided  to  examine  the  patient  under  anesthesia,  having  everything 
ready  to  operate  in  case  the  mass  proved  to  be  extrauterine.  Under  the  complete  relaxa- 
tion of  anesthesia  I  was  able  to  determine  that  the  cervix  expanded  symmetrically  into 
the  mass,  which  was  thus  identified  as  the  body  of  the  uterus.  It  was  found,  however,  to 
be  twice  as  large  as  it  should  be  at  that  period  of  pregnancy.  This  abnormal  enlarge- 
ment with  the  prolonged  bloody  discharge  and  the  increasing  pain  made  it  evident  that 
there  was  some  serious  pathologic  condition  within  the  uterus  and  not  a  normal  preg- 
nancy. I  dilated  the  cervix  slightly,  and  there  escaped  several  small  cysts.  That  made 
the  diagnosis  plain,  and  I  then  dilated  the  cervix  widely  and  removed  from  the  uterus  a 
beautiful  specimen  of  hydatidiform  mole.  The  uterine  cavity  was  literally  packed  with 
the  grape-like  bunches  of  minute  cysts  characteristic  of  this  condition.  No  trace  of  a 
fetus  was  found.  The  patient  recovered  without  further  trouble,  and  has  since  given 
birth  to  two  children,  the  pregnancy,  labor  and  jjuerperium  in  each  case  being  normal. 

Pregnancy  with  Hysteria  and  Uterine  Displacement.  While  I  was  in  charge  of  our 
city  hospital  for  women  (St.  Louis  Female  Hospital)  a  patient  was  brought  into  that 
institution  on  a  stretcher,  suffering  severe  abdominal  pain  and  apparently  very  ill.  The 
suffering  was  so  great  that  the  history  was  obtained  with  difficulty.  She  had  missed  the 
menses  about  four  months,  and  the  usual  symptoms  of  pregnancy  had  been  succeeded  by 
irregular  attacks  of  pain,  which  culminated  in  the  severe  attack  which  caused  her  to  be 
hurried  to  the  hospital. 

Examination.  The  abdomen  was  sensitive  and  the  muscles  rigid.  In  the  right  lower 
abdomen  there  wfis  a  distinct  mass,  very  painful  to  touch.  On  bimanual  examination  it 
was  found  that  this  mass  extended  down  into  the  right  side  of  the  pelvis,  which  it  largely 
filled.  It  was  about  the  size  of  a  child's  head,  extremely  tender,  apparently  fixed  and 
presenting  indistinct  fluctuation.  The  cervix  was  somewhat  softened.  The  body  of  the 
uterus  could  not  be  made  out  on  account  of  the  marked  tenderness  and  the  resulting 
muscular  rigidity,  which  interfered  with  deep  palpation.  The  pulse  was  rapid,  but  of  fair 
volume.  There  was  no  fever.  I  was  quite  certain  that  the  trouble  was  extrauterine 
pregnancy.  Examination  under  anesthesia,  however,  showed  that  it  was  an  intrauterine 
pregnancy.  The  fixed  and  tender  mass  in  the  right  side  was  the  pregnant  uterus,  which 
was  freely  movable  under  anesthesia. 

After  the   examination   the   symptoms   largely    disappeared    and   the   patient   was    able 


894  EXTRAUTERINE   PREGXAXCY 

to  leave'  the  hospital  in  a  short  time.  Tlie  misleading  features  were  the  severe  abdom- 
inal pain  and  tenderness,  associated  with  a  lateral  pelvic  mass,  which  was  extremely  ten- 
der (hysterical  hyperesthesia)  and  fixed  (by  the  rigid  condition  of  the  abdominal  muscles), 
and  which  could  not  be  identified  as  the  body  of  the  uterus  (because  of  the  marked 
softening  just  above  the  cei-vix,  and  also  because  of  the  impossibility  of  deep  palpation). 
Anesthesia  removed  the  difiieulties  and  at  once  permitted  a  correct  diagnosis. 

TMs  case  and  the  preceding  one  serve  to  emphasize  the  necessity  of  care- 
ful examination  nnder  anesthesia  before  operation  in  all  snch  doubtful  or  un- 
certain cases.  It  must  be  kept  in  mind,  however,  that  when  tubal  pregnancy 
is  suspected,  the  patient  should  be  placed  in  a  hospital  and  prepared  for  oper- 
ation before  the  examination  under  anesthesia  is  made,  for  if  the  trouble  is 
tubal  pregnancy  the  manipulations  of  the  examination  may  cause  rupture  and 
hemorrhage,  requiring  immediate  operation. 

Pregnancy  with  Irregixla^r  Softening  of  Uterus.  A.  patient  with  supposed  extrauterine 
pregnancy  was  brought  to  St.  Louis  by  her  physician  _  and  placed  under  my  care.  About 
five  months  pre-\-iously  she  had  missed  her  menses  and  presented  the  usual  symptoms  of 
pregnancy.  Three  months  later  she  had  abdominal  pains  accompanied  by  a  bloody  dis- 
charge from  the  uterus.  The  bleeding  stopped,  but  the  pain  recurred  at  irregular  inter- 
vals and  there  was  an  enlarging  mass,  which  could  not  be  identified  as  part  of  the  uterus. 
Her  physician  called  several  others  in  consultation  and  the  consensus  of  opinion  was  that 
the  pregnancy  was  extrauterine;   hence   she  was  brought  to  St.  Louis  for  operation. 

Examination.  I  found  a  very  puzzling  condition.  The  body  of  the  uterus  was  irregu- 
lar in  shape  and  irregularly  softened,  and  gave  at  first  the  impression  of  a  fairly  firm 
mass  not  connected  with  the  cervix,  the  poi-tion  immediately  above  the  cervix  being  so 
softened  as  to  be  hardly  palpable.  After  examining  for  some  time  it  was  finally  deter- 
mined that  the  mass  was  the  enlarged  and  pregnant  corpus  uteri.  The  rhythmical  hard- 
ening of  the  uterine  wall  aided  materially  in  the  differentiation.  By  prolonging  the  exam- 
ination I  was  able  to  feel  the  previously  softened  portion  harden  under  the  finger,  and 
could  then  make  out  that  the  upper  part  of  the  cervix  expanded  symmetrically  into  the 
mass  in  question.  After  working  out  the  diagnosis  I  was  able  to  demonstrate  it  satisfac- 
torily to  the  patient's  physician,  who  examined  her  with  me. 

Pregnancy  with  Retroflexed  Uterus.  Reported  by  Royster,  aged  22,  married  sixteen 
months,  missed  her  menses  three  times  in  succession,  had  nausea  and  vomiting,  and  also 
tenderness  of  the  breasts.  Then  she  had  an  attack  resembling  cholera  morbus  and  a  slight 
bloody  stain  from  the  genitals,  but  no  distinct  hemorrhage.  The  sigTis  of  pregnancy  then 
became  less  marked.  She  complained  of  pain  in  the  lower  abdomen,  especially  in  the  left 
side,  and  of  frequent  and  painful  urination. 

Examination.  There  was  found  a  mass  chiefly  in  the  left  side  of  the  pelvis  and 
pressing  down  the  posterior  A^aginal  fornix.  It  was  boggy  and  tender  to  the  touch.  The 
uterus  appeared  to  be  pushed  to  the  right  side  and  was  intimately  associated  with  the 
mass.  A  sound  was  readily  introduced  into  the  uterus  to  the  depth  of  three  inches,  indi- 
cating that  the  uterus  was  about  normal  in  depth  and  was  empty.  A  diagnosis  of  extra- 
uterine pregnancy  was  made  and  the  patient  operated  on  accordingly. 

Operation.  This  revealed  a  retroverted  pregnant  uterus,  twisted  somewhat  toward 
the  left,  and  with  the  wall  softened  irregularly.  Tliere  was  no  extrauterine  pregnancy. 
The  uterus  was  brought  into  correct  position  and  a  small  cyst  of  the  ovary  removed.  The 
patient  recovered  witiiout  incident   and  the  ftregiiancy  coiitinued. 

Pregnancy  and  Salpingitis.  Reported  by  Leopold.  Patient,  aged  32,  mother  of  five 
children,   missed   menstruation   and  had    abdominal   pains    and   bloody   discharge.      Examina- 


CONDITIONS    SIMULATING    TUBAL    PREGNANCY  895 

tion  showed  a  painful  mass  occupying  the  posterior  cul-de-sac.  Diagnosis,  extrauterine 
pregnancy.  Operation  revealed  an  intrauterine  pregnancy,  with  an  associated  salpingo- 
oophoritis,  probably  of  gonorrheal  origin.  The  mass  formed  by  the  inflamed  tube  and 
ovary  was  low  in  the  cul-de-sac.     Patient  recovered. 

Pregnancy  with  Torsion  of  Enlarged  Tvihe.  Eeported  by  Morel.  Patient,  aged  32, 
mother  of  four  cliildren,  missed  menstruation.  After  a  time  she  was  seized  with  severe 
pain  in  the  left  lower  abdomen,  had  vomiting,  rapid  pulse  and  no  fever.  The  uterus  was 
somewhat  enlarged  and  softened,  and  a  tumor  was  felt  back  of  it.  Operation  showed  a 
pregnant  uterus  with  a  posterior  mass,  as  large  as  a  turkey's  egg,  formed  by  the  left 
tube.  The  pedicle  of  the  enlarged  tube  was  twisted  six  times  and  the  interior  was  filled 
with  blood   (hematosalj)inx). 

Tumor  with  Anomalous  Symptoms.  When  a  pelvic  tumor,  previously  un- 
recognized, happens  to  be  accompanied  "svitli  missed  menstruation  and  sudden 
pain  and  decided  tenderness,  the  resemblance  to  tubal  pregnancy  may  be  most 
misleading. 

Broad  Ligajnent  Cyst,  with  Intracystic  Hemorrhage.  Mrs.  D.,  aged  26,  admitted  to 
the  Gynecologic  Department  of  Washington  University  Hospital.  Married  five  months. 
Previous  menstrual  history  normal — menses  regular  in  appearance,  duration  four  days,  no 
pain.  One  month  after  marriage  menstruation  was  missed  for  seven  days.  Then  a  bloody 
flow  appeared.  It  was  profuse,  accompanied  by  clots  and  lasted  about  nine  days.  About 
two  weeks  later  the  patient  had  a  fall,  which  was  followed  by  pain  in  the  left  side  of  the 
pelvis  and  lower  abdomen,  and  this  persisted  The  succeeding  months  there  was  a  men- 
strual flow,  but  it  was  less  than  the  usual  amount.  The  patient  continued  sick,  and  had 
to  give  up  work  and  was  obliged  to  lie  down  at  times.  There  was  loss  of  appetite  and  for 
two  months  decided  nausea  when  riding  in  a  car,  but  this  became  less.  There  was  also 
tenderness  of  the  breasts,  which  had  diminished  during  the  last  month.  There  had  been 
no  fever.  The  patient  complained  of  pain  in  the  left  lower  abdomen.  Temperature  was  99°, 
pulse  90,  and  respiration  20. 

Examination.  The  uterus  was  found  forward,  to  the  right  and  movable.  The  left 
side  of  the  pelvis  was  occupied  by  a  mass  the  size  of  a  large  orange,  fluctuating  and  ten- 
der on  palpation.  The  diagnosis  was  doubtful,  with  the  probability  in  favor  of  tubal 
pregnancy. 

Operation.  This  revealed  a  parovarian  tumor  (cyst)  into  which  hemorrhage  had  taken 
place.  Tlie  cyst  was  easily  enucleated  from  its  bed  in  the  broad  ligament,  and  subsequent 
examination  of  it  in  the  laboratory  positively  excluded  extrauterine  i^regnancy.  The  pa- 
tient recovered  without  particular  incident. 

Parovarian  Cyst  with  Twisted  Pedicle  and  Salpingitis.  Patient,  aged  22,  admitted 
to  Gynecologic  Department  of  "Washington  University  Hospital,  very  ill  and  complaining 
of  pain  through  the  lower  abdomen. 

Examination.  A  large  mass  was  found,  filling  the  right  side  of  the  pelvis  and  ox- 
tending  up  into  the  lower  abdomen,  half  way  to  the  umbilicus.  This  was  painful  on  pal- 
pation and  indistinct  fluctuation  could  be  made  out.  The  uterus  was  pushed  to  the  left. 
All  the  pelvic  structures  were  apparently  bound  together  and  fixed  by  adhesions.  Patient 
was  pale  and  complained  of  a  constant  pain  in  the  abdomen,  of  a  dull  character.  Tem- 
perature, 99°;  imlse,  80;  respiration,  20.  For  ten  weeks  past,  the  menstruation  had  been 
very  irregidar.  For  nearly  a  month  there  was  a  constant  bloody  discharge,  then  it  stopped 
for  a  few  days,  then  came  on  again  for  a  few  days,  and  then  stopped  entirely.  For  five 
weeks  before  entering  the  hospital  there  was  no  menstruation,  not  even  a  trace  of  blood. 
There  was  free  muco-purulent  discharge.  During  the  period  mentioned  there  had  been  con- 
siderable  pain   throughout   the    abdomen,    and    two   weeks   before    entering   the    hospital   the 


896  •  EXTRAUTERINE   PREGNANCY 

patient  had  had  a  very  severe  attack  of  pain.  She  was  confined  to  bed  for  a  few  days  and 
had  been  lying  down  off  and  on  ever  since.  The  mass  was  too  large  and  of  too  rapid  develop- 
ment to  be  due  to  the  inflammation,  which  was  apparently  of  mild  grade.  There  was  no 
previous  history  of  a  tumor.  There  had  been  some  pain,  off  and  on,  during  the  previous 
year,  but  nothing  to  suggest  serious  trouble. 

The  patient  was  kept  under  observation  for  seven  days.  The  temperature  ranged 
from  98°  to  99.4°,  once  going  to  100°,  but  never  higher.  The  pulse  ranged  from  80  to  92. 
The  mass  continued  to  enlarge  and  the  pain  increased,  requiring  sedatives,  in  spite  of 
the  fact  that  the  patient  was  kept  absolutely  quiet  in  bed  and  that  the  temperature  con- 
tinued low.  There  had  been  a  tentative  diagnosis  of  tubal  pregnancy,  and  this  progress 
under  observation  and  the  continued  absence  of  the  menstruation  tended  to  confirm  it. 

Operation.  The  mass  was  found  to  be  a  parovarian  cyst  with  twisted  pedicle,  uni- 
versal adhesions  and  a  complicating  pyosalpinx  of  the  same  side.  Free  drainage  was  em- 
ployed and  the  patient  recovered. 


Abdominal  Pain  and.  Collapse 

When  a  married  woman  in  the  child-bearing  period  is  seized  with  severe 
abdominal  pains,  without  apparent  cause,  and  passes  into  the  condition  of 
collapse  associated  Avith  severe  internal  hemorrhage,  we  naturally  think  of 
ruptured  tubal  pregnancy  as  the  most  probable  cause.  If  there  happens  to 
be  missed  menstruation  or  some  of  the  other  symptoms  of  tubal  pregnancy, 
and  the  examination  reveals  nothing  else  to  account  for  the  pain  an4  shock, 
a  tentative  diagnosis  of  tubal  pregnancy  and  action  accordingly  is  certainly 
justified.  As  prompt  action  may  be  necessary  to  save  the  patient's  life,  such 
action  must  sometimes  be  taken  on  evidence  which  would  be  considered  in- 
sufficient were  the  indications  less  urgent.  Under  such  conditions  the  diag- 
nosis of  ruptured  tubal  pregnancy  is  largely  a  matter  of  exclusion,  for,  as  pre- 
viously stated,  the  pelvic  examination  often  gives  no  definite  evidence  be- 
yond the  tenderness.  Hence  the  importance  of  carefully  considering  other 
conditions  that  may  cause  these  symptoms.  There  are  many  such  conditions, 
but  only  certain  ones  will  be  mentioned  which  are  especially  liable  to  be  con- 
founded with  ruptured  tubal  gestation. 

Hemorrhage  from  Ovary.  Weinbrenner  reports  two  eases  in  which  hemorrhage  into 
a  6orpus  luteum,  already  in  cystic  degeneration,  burst  the  wall  of  the  cyst.  Free  hemor- 
rhage into  the  peritoneal  cavity  followed.  In  one  instance  the  tendency  to  hemorrhage 
was  increased  by  torsion  of  the  pedicle  of  the  cystic  ovary.  The  clinical  diagnosis  in  each 
case  was  extrauterine  pregnancy,  but  microscopic  examination  of  the  removed  specimen 
showed  positively  that  there  was  no  pregnancy. 

In  cases  of  ovarian  hemorrhage,  care  must  be  taken  to  exclude  ovarian 
pregnancy  at  the  site  of  the  hemorrhage  before  deciding  that  it  is  due  to 
some  other  condition.  Some  of  the  so-called  ''blood  cysts"  of  the  ovary 
are,  no  doubt,  unrecognized  instances  of  ovarian  pregnancy.  The  following 
is  a  case  in  point :  Reported  by  J.  K.  Kelly.  He  operated  on  a  woman,  aged 
33,  for  supposed  extrauterine  pregnancy  and  found  only  a  blood  cyst  of  the 
ovary  about  the  size  of  a  plum.     The  ovary  was  removed  and  the  case  set 


CONDITIONS    SIMULATING    TUBAL   PREGNANCY  897 

doAvn  as  one  of  mistaken  diagnosis.  Some  months  later,  and  quite  incident- 
ally, a  microscopic  section  was  made  through  the  wall  of  the  little  cyst,  and 
examination  of  this  showed  chorionic  villi.  A  careful  and  systematic  exam- 
ination was  then  made  of  the  small  cyst  and  its  surroundings,  and  it  proved 
to  be  a  beautiful  specimen  of  early  ovarian  pregnancy. 

Ovarian  Cyst  with  Rupture.  Eeporled  by  Yineberg.  In  his  office  he  was  examining 
a  woman  on  account  of  discomfort  in  the  lower  abdomen  associated  with  delayed  men- 
struation. The  patient  was  stout  and  the  bimanual  examination  was  difficult.  The  uterus 
was  enlarged  and  to  the  left  of  it  was  a  cystic  mass  the  size  of  a  small  orange.  "\Miile 
palpating  this  mass  it  suddenly  ruptured  and  the  patient  promptly  went  into  syncope.  It 
was  supposed  that  a  tubal  gestation  sac  had  ruptured,  with  resulting  intraperitoneal  hem- 
orrhage. After  a  little  time  the  patient  rallied,  and  as  the  symptoms  were  then  not  so 
urgent  she  was  kept  under  observation  for  a  couple  of  days.  Improvement  was  so  marked 
that  it  was  decided  that  the  ruptured  mass  must  have  been  only  a  small  cyst  of  the 
ovary  instead  of  a  tubal  pregnancy.     Tliere  was  no   further  trouble. 

Hematosalpinx  with  Severe  Bleeding.  Brettauer  reported  a  ease  of  severe  internal 
hemorrhage,  supposedly  due  to  ruptured  tubal  pregnancy.  The  patient  went  into  collapse 
and  became  too  weak  for  operation.  Later  she  rallied  and  the  operation  was  carried  out. 
A  hemorrhagic  swelling,  the  size  of  a  walnut,  was  found  in  the  middle  third  of  one  tube. 
From  this  the  severe  bleeding  had  taken  place.  The  inner  and  outer  portion  of  the  tube 
were  apparently  normal.  The  swollen  area  had  the  appearance  of  a  tubal  pregnancy  and 
was  excised  as  such.  When  sectioned  and  examined  microscopically,  no  tubal  pregnancy 
was  found.  The  specimen  was  then  sectioned  serially  and  examined  most  carefully,  and 
the  result  was  absolutely  negative  so  far  as  evidence  of  tubal  pregnancy  was  concerned. 

The  fact  is  sometimes  overlooked  that  tubal  swellings  of  hemorrhagic  character  are 
not  necessarily  due  to  pregnancy  in  that  situation.  Since  Tait's  famous  dictum,  that 
"hematosalpinx  is  always  due  to  extrauterine  pregnancy,"  there  has  been  a  tendency 
among  operators  to  look  on  this  as  a  rule  without  exceptions.  That  there  are  exceptions, 
however,  there  is  abundant  proof.  A  number  of  well-established  cases  have  been  reported. 
As  a  rule,  such  differentiation  is  not  of  great  practical  moment,  for  the  reason  that  treat- 
ment of  the  two  conditions  is  the  same;  namely,  removal  of  the  damaged  tube.  In  some 
eases,  however,  it  may  be  extremely  important  to  determine  certainly  the  character  of  the 
mass  before  expressing  an  opinion  as  to  what  it  is.'  Some  years  ago  a  pupil  nurse  in  one 
of  the  local  hospitals  was  attacked  with  serious  abdominal  disturbance  requiring  operation. 
When  the  abdomen  was  opened  there  was  found  a  hemorrhagic  condition  of  one  tube  re- 
sembling tubal  pregnancy.  The  operator  at  once  pronounced  it  tubal  pregnancy  in  the. pres- 
ence of  several  internes  and  nurses.  The  information  spread  through  the  hospital  with  a 
result  to  be  easily  imagined.  The  young  woman  recovered  from  the  serious  operation  only 
to  find  herself  in  a  situation  almost  unbearable,  and  she  finally  left.  In  the  meantime, 
examination  of  the  mass  by  a  competent  pathologist  showed  that  it  was  not  a  tubal  pregnancy 
and  that  a  most  serious  mistake  had  been  made  in  pronouncing  it  such. 

Tubo-ovarian  Hemorrhage.  Bovee  reported  a  ease  in  which,  at  operation,  there  was 
found  a  tubo-ovarian  hemorrhagic  mass,  supposed  to  be  tubal  pregnancy,  but  which  proved 
to  be  only  inflammatory.  Both  the  tube  and  ovary  were  distended  with  blood,  and  there 
was  a  small  opening  through  the  fimbriated  extremity  connecting  the  two  cavities.  The 
hemorrhage  apparently  originated  in  the  ovary,  and  the  free  intraperitoneal  bleeding  came 
through  a  small  rupture  in  the  wall  of  the  ovarian  blood-cyst.  A  thorough  microscopic 
examination  demonstrated  that  there  was  no  pregnancy  either  in  the  tube  or  ovary. 


898  EXTRAUTERINE  PREGNANCY 

Bovee  mentioned  cases  of  tubal  and  ovarian  hemorrhage,  not  due  to.  ex- 
trauterine pregnancy  reported  by  Price,  Newman,  Griffiths,  Briggs,  Groom,  Paul, 
Ruge,  Goodell,  Duncan,  Pilliet,  Maurange,  Puech  and  Doran.  He  referred  also 
to  cases  occurring  in  virgins  at  an  early  age,  reported  by  Fordyce;  to  fatal 
cases  reported  by  Walter,  Lewis  and  Fowder ;  to  cases  successfully  treated 
by  abdominal  section,  reported  by  Boldt,  Allow^ay,  Knaggs,  and  Johnson,  and 
to  the  celebrated  case  of  Scanzoni  in  which  at  an  autopsy  on  the  body  of 
a  young  girl,  dying  suddenly  during  menstruation,  three  liters  of  blood  were 
found  in  the  peritoneal  cavity.  These  hemorrhages  from  the  non-pregnant 
ovary  (ovarian  apoplexy,  blood-cysts,  follicular  hemorrhage,  etc.),  and  from 
the  non-pregnant  tube  (hematosalpinx)  are  usually  due  to  inflammatory 
changes,  causing  degeneration  of  the  tissues  and  of  the  contained  blood  ves- 
sels.    Occasionally  a  tumor  of  the  ovary  or  tube  is  the  causative  lesion. 

Many  other  conditions  have  been  mistaken  for  tubal  pregnancy  (on  ac- 
count of  sudden  collapse  associated  with  abdominal  pain) — for  example,  hem- 
orrhage from  a  varicose  vein  of  the  broad  ligament,  salpingitis  with  collapse, 
perforative  appendicitis  with  a  pelvic  tumor,  and  fulminating  pelvic  edema. 
Numerous  illustrative  cases  have  been  reported,  but  there  is  not  space  for 
them  here.     Fulminating  pelvic  edema  will  be  considered  later    (page  905). 

Conclusions 

1.  Gonorrheal  pyosalpinx,  after  the  acute  symptoms  subside,  may  lie 
dormant  and  unsuspected  for  a  long  period  (four  years  in  one  reported  case). 
During  this  quiescent  period  the  pus  tube  (containing  sterile  pus  usually)  is 
tolerated  the  same  as  a  small  tumor  or  other  non-irritating  body— the  patient 
being  practically  well  and  without  decided  pelvic  disturbance. 

Such  a  quiescent  pus  tube  may  at  any  time  give  rise  to  an  acute  exacer- 
bation, and  the  onset  of  the  pain  may  be  so  sudden  and  apparently  causeless 
as  to  suggest  tubal  pregnancy.  This  suggestion  is  strengthened  by  the  con- 
tinued enlargement  of  the  mass  (from  irritative  exudate)  ^^ithout  decided 
fever  (for  the  pus  is  sterile).  Accompanying  the  exacerbation  or  preceding  it- 
there  are  sometimes  other  symptoms  that  we  associate  with  tubal  pregnancy 
— viz.,  missed  menstruation,  stomach  disturbance,  tenderness  of  the  breasts, 
and  softening  of  the  cervix  uteri.  The  last  three  are  accounted  for  by  the 
peritoneal  and  periuterine  irritation  and  congestion,  but  why  there  should 
be  delayed  or  missed  menstruation  at  this  inopportune  time  can  not  be  said. 
One  would  suppose  that  the  irritation  and  pelvic  congestion  would  cause 
the  menstrual  flow  to  be  excessive  rather  than  absent.  It  is  possible  that  the 
temporary  suppression  of  menstruation  (from  some  nervous  disturbance  or 
other  obscure  cause)  stands  in  a  causative  relation  to  the  acute  exacerbation 
with  its  subsequent  symptoms.  This  can  be  offered  simply  as  a  suggestion 
toward  a  possible  explanation  of  this  strange  and  misleading  sequence  of  events 
(the  missed  menstruation  followed  by  the  other  symptoms  detailed). 


CONDITIONS   SIMULATING   TUBAL   PREGNANCY  899 

In  cases  of  supposed  tubal  pregnancy  of  the  type  mentioned,  particular 
care  should  be  taken  to  exclude  chronic  gonorrheal  salpingitis,  as  follows: 
(a)  by  inquiring  into  the  patient's  history  for  evidences  of  specific  vaginitis  or 
urethritis,  and  for  subsequent  pelvic  symptoms  (an  inquiry  into  the  hus- 
band's history  also  may  bring  out  valuble  information);  (b)  by  a  careful 
examination  for  evidences  of  a  chronic  urethritis.  Bartholinitis,  endometritis 
or  salpingitis;  and  (c)  by  staining  for  the  gonococcus  any  suspicious  discharge 
that  may  be  obtained  from  the  urethra,  vulvo-vaginal  glands,  uterus  or  va- 
gina. In  chronic  cases  negative  findings  do  not  exclude  gonorrhea,  for  the 
gonococcus  disappears  from  the  discharge  after  a  time. 

2.  In  rare  cases  acute  gonorrhea  may  extend  rapidly  through  the  uterus 
to  the  tubes  and  peritoneum,  with  so  little  disturbance  of  the  vagina  and  vulva 
as  to  arouse  no  suspicion  of  its  presence.  In  such  a  case  the  acute  peritoneal 
symptoms  will  come  on  suddenly  and  without  apparent  cause.  If  there  hap- 
pens to  be  also  delayed  or  scanty  menstruation,  tubal  pregnancy  may  be  sus- 
pected. And  this  suspicion  is  strengthened  by  the-  stomach  disturbance,  the 
softening  of  the  cervix  and  the  enlarging  mass  beside  the  uterus.  In  a 
case  above  mentioned  the  diagnosis  was  further  obscured  by  the  curetment, 
which  modified  the  discharge,  and  by  the  continued  low  temperature,  which 
seemed  to  exclude  acute  inflammation.  In  all  such  doubtful  cases  with  acute 
discharge  it  is  advisable  to  examine  for  gonococci,  even  though  the  discharge 
be  scanty  and  bloody  and  apparently  non-purulent. 

3.  An  early  miscarriage,  if  associated  with  a  tumor  or  followed  by  mild 
salpingitis,  may  very  closely  simulate  tubal  pregnancy.  Membranes  may  be 
passed  in  either  condition.  With  a  miscarriage  there  is  an  embryo,  but  it 
often  passes  unnoticed.  If  a  shred  of  tissue  is  passed,  it  may  be  examined  for 
chorionic  structures.  In  a  case  which  can  not  be  decided  otherwise,  curet- 
ment is  advisable  to  obtain  tissue  for  microscopic  examination  for  chorionic 
villi.  But  in  suspected  tubal  pregnancy  such  a  curetment  should  not  be  car- 
ried out  until  the  patient  is  in  a  hospital  and  prepared  for  abdominal  sec- 
tion, for  the  manipulations  may  start  internal  hemorrhage,  requiring  oper- 
ation at  once. 

4.  A  pregnant  uterus  may  present  very  misleading  conditions ;  e.  g.,  ir- 
regular softening  (so  much  so  that  the  body  seems  to  be  a  firm  mass  entirely 
separate  from  the  cervix),  displacement,  backward  or  forward  or  laterally; 
hyperesthesia  with  displacement,  or  irregular  softening  or  an  associated  lateral 
mass  (salpingitis,  etc.).  If  there  is  in  addition  an  anomalous  history,  a  mis- 
take is  quite  probable. 

5.  An  unsuspected  tumor  in  the  pelvis  may  give  rise  suddenly  to  severe 
disturbance,  and  if  there  happen  to  be  present  also  some  of  the  symptoms  of 
early  pregnancy,  a  diagnosis  of  extrauterine  pregnancy  is  very  probable.  The 
cases  mentioned  above  show  that  the  early  symptoms  of  pregnancy  (missed 
menstruation,  stomach  disturbance,  breast  tenderness  and  softened  cervix 
uteri)  often  appear  without  satisfactory  cause  and  at  most  inopportune  times. 


900  EXTRAUTERIXE    PREGXAXCY 

6.  Ovarian  hemorrhage  or  tubal  hemorrhage,  due  to  other  conditions, 
may  so  closely  simulate  extrauterine  pregnancy  as  to  be  indistinguishable  be- 
fore operation,  and  in  some  cases  the  matter  is  in  doubt  even  after  direct  ex- 
posure and  handling  of  the  affected  structures.  In  this  connection  there  are 
three  points  to  be  kept  in  mind:  (a)  There  may  be  slight  hemorrhage  from 
the  tube  or  ovary,  particularly  at  the  period  of  menstrual  congestion  not  due 
to  extrauterine  pregnancy  and  not  requiring  operation,  (b)  In  cases  of  tubal 
hemorrhage  requiring  operation  the  hemorrhagic  condition  of  the  tube  is 
not  necessarily  due  to  pregnancy,  and  in  doubtful  eases  should  not  be  pro- 
nounced such  until  after  confirmation  by  microscopic  examination,  (c)  In  a 
hemorrhagic  condition  of  the  ovary  requiring  removal  of  the  same,  a  careful 
examination  should  be  made  to  determine  exactly  the  pathologic  condition. 
Such  a  supposed  simple  "blood  cyst"  of  the  ovary  may  prove  on  careful 
microscopic  examination  to  be  an  early  ovarian  pregnancy. 

7.  Salpingitis,  appendicitis  and  perforations  in  the  gastro-intestinal  tract 
may  in  rare  cases,  come  on  so  suddenly  and  progress  so  rapidly  as  to  suggest 
internal  hemorrhage  from  extrauterine  pregnancy.  Usually  in  these  condi- 
tions there  are  preceding  or  accompanying  symptoms  which  point  to  the  true 
nature  of  the  disease.  If  these  distinctive  features  are  absent  and  there  hap- 
pen to  be  some  of  the  other  symptoms  of  tubal  pregnancy,  a  mistaken  diag- 
nosis is  probable. 

8.  Fulminating  pelvic  edema,  with  its  sudden  onset  and  the  rapid  devel- 
opment of  alarming  symptoms,  may  closely  resemble  extrauterine  pregnancy. 
In  one  case,  cited  later,  the  temperature  vas  so  high  that  it  vas  easily 
distinguished  as  an  inflammatory  trouble  and  not  a  hemorrhage,  but  in  other 
reported  cases  this  feature  was  lacking  and  mistaken  diagnoses  of  extrauter- 
ine pregnancy  were  made.  In  this,"  as  in  other  conditions  of  non-hemorrhagic 
shock  or  depression,  there  is  not  the  persistently  blanched  condition  of  the 
skin  so  characteristic  of  profuse  hemorrhage.  The  pulse,  also,  though  rapid, 
is  likely  to  have  better  volume  than  after  a  severe  hemorrhage. 

9.  It  is  evident  that  the  diagnosis  of  extrauterine  pregnancy  must  rest  on 
the  combination  of  several  symptoms.  Xo  one  fact  is  sufficient,  and  it  is 
hazardous  to  depend  on  two  or  three  facts  unless  they  are  especially  strong 
and  well  marked.  In  most  cases  the  diagnosis  inust  be  reached  by  a  careful 
consideration  of  all  the  symptoms  present  and  the  definite  exclusion,  one  by 
one,  of  other  conditions  which  may  produce  similar  symptoms. 

Treatment 

In  pointing  out  the  treatment  for  extrauterine  pregnancy,  several  clinical 
classes  must  be  considered — namely  (1)  before  rupture,  (2)  hematocele,  (3) 
repeated  moderate  intraperitoneal  hemorrhage,  (4)  profuse  intraperitoneal 
hemorrhage,  (5)  hematoma,  and  (6)  advanced  cases. 

1.  Before  Rupture.     The  only  safe  line  of  treatment  in  this  stage  is  ab- 


treat:ment  901 

dominal  section  and  removal  of  the  pregnant  tube  as  soon  as  the  diagnosis  is 
fairly  certain.  The  patient  is  in  constant  danger  of  a  sudden  serious  hemor- 
rhage, hence  the  sooner  she  is  operated  on  the  better.  If  the  tube  is  lying  low 
in  the  cul-de-sac,  it  might  be  reached  and  ligated  from  below  (vaginal  sec- 
tion), but  this  is  not  an  entirely  safe  undertaking.  The  manipulations  may 
serve  to  start  a  sudden  severe  hemorrhage  which  could  not  be  promptly 
checked  from  below,  particularly  as  these  pregnant  tubes  are  frequently  bound 
in  place  by  old  adhesions.  The  safest  operation  in  this  stage  is  removal  of 
tlie  pregnant  tube  by  abdominal  section. 

2.  Pelvic  Hematocele  (Fig.  703).  In  these  cases  the  hemorrhage  has  long 
since  ceased  and  the  collection  of  blood  in  the  pelvic  cavity  is  well  shut  off 
from  the  general  peritoneal  cavity  by  plastic  exudate  and  adhesions.  The 
embryo  and  membranes  have  probably  escaped  from  the  tube,  either  through 
a  rupture  in  the  wall  or  more  f reciuently  through  the  end  of  the  tube  by 
"tubal  abortion,"  and  perhaps  have  been  largely  absorbed. 

Practically  all  that  remains  is  the  blood  in  the  pelvis,  with  the  exudate  and 
adhesions  around  it.  This  forms  a  tender  mass  low  in  the  cul-de-sac  back  of 
the  uterus,  without  much  disturbance  higher. 

In  such  a  case  it  is  well  to  watch  the  patient  for  a  while,  in  the  meantime 
keeping  her  c^uiet  in  bed.  In  the  course  of  a  week  or  ten  days  there  will 
probably  be  decided  improvement,  showing  that  Nature  is  taking  care  of 
the  blood  and  exudate  and  that  the  patient  will  probably  recover  Avithout  oper- 
ation, or  renewed  evidences  of  irritation  will  appear,  showing  that  em- 
bryo and  chorion  are  still  growing  or  that  the  blood  and  exudate  are  acting 
as  a  persistent  source  of  irritation.  When  there  is  persistent  irritation  af- 
ter this  period  of  rest,  operation  is  indicated. 

The  choice  of  operation  depends  on  the  circumstances  of  the  case.  If 
the  evidences  of  irritation  (pain  and  tenderness)  are  all  low  in  the  cul-de-sac, 
the  possibility  is  that  evacuation  of  the  blood  from  the  cul-de-sac  by  vaginal 
section  will  be  all  that  is  necessary.  If  the  pain  and  tenderness  extend  into 
the  upper  part  of  the  pelvis,  abdominal  section  is  the  safer  operation.  When 
the  conditions  are  doubtful,  the  abdominal  route  should  be  chosen. 

In  a  case  Avhere  a  hematocele  is  to  be  evacuated  by  vaginal  section,  the 
patient  should  be  prepared  for  an  abdominal  section  also,  for  there  is  a  pos- 
sibility of  the  vaginal  manipulations  starting  an  internal  hemorrhage  Avhich 
could  not  be  satisfactorily  controlled  from  below. 

3.  Repeated  Moderate  Intraperitoneal  Hemorrhage  (Fig.  704).  This  class 
comprises  the  majority  of  the  cases  of  tubal  pregnancy.  The  usual  course  of 
such  a  case  is  well  shown  in  the  typical  case  previously  described  (page  885). 
The  treatment  is  abdominal  section  as  soon  as  the  diagnosis  is  positive  and 
the  patient  can  be  placed  in  a  hospital  and  given  the  regular  careful  prepara- 
tion for  that  operation. 

4.  Profuse  Intraperitoneal  Hemorrhage  (Figs.  705,  706).  In  these  cases 
immediate  abdominal  section  is  advisable  as  a  rule  if  the  patient  is  within 


902  EXTRAUTERINE   PREGNANCY 

reach  of  an  experienced  abdominal  surgeon  and  can  be  placed  in  suitable 
surroundings.  In  the  absence  of  an  experienced  operator  and  suitable  facil- 
ities, operation  had  best  be  deferred. 

In  operations  for  the  various  classes  of  cases  of  extrauterine  pregnancy, 
as  well  as  other  conditions  in  which  abdominal  section  is  required,  the  pa- 
tient's chance  of  recovery  is  greater  if  the  operation  can  be  conducted  in- a 
well-ordered  hospital.  Consequently,  the  patient  should  be  taken  to  a  hos- 
pital if  possible.  Even  a  trip  on  the  train,  with  the  patient  on  a  stretcher  and 
in  a  strictly  recumbent  posture  all  the  time,  is  less  hazardous  than  operation 
in  poor  surroundings.  The  marked  emphasis  w^hich  teachers  and  writers 
generally  have  placed  upon  promptness  of  operation  in  extrauterine  preg- 
nancy has  unfortunately  led  to  considerable  indiscriminate  operating  in 
these  cases— operations  on  patients  in  which  it  would  have  been  safer  to 
wait  a  while,  operations  without  adequate  antiseptic  preparation,  operations 
by  persons  without  sufficient  surgical  experience  to  handle  the  serious  intra- 
abdominal conditions  in  a  safe  and  effective  way.  Even  in  the  restricted 
class  of  cases  in  which  there  is  free  intraperitoneal  hemorrhage,  the  so-called 
''tragic"  cases,  it  is  probable  that  not  many  patients  really  die  at  once  from 
the  loss  of  blood.  There  are  some  that  do,  but  they  are  comparatively  few, 
as  indicated  by  mortuary  records  and  by  the  number  of  patients  that  come  to 
operation  later  with  a  history  of  having  passed  through  a  severe  attack  of 
intraperitoneal  hemorrhage.  It  is  the  repeated  hemorrhages,  with  the  re- 
sulting peritoneal  irritation  and  inflammation  coming  on  within  a  few  days 
or  a  few -weeks,  that  constitute  the  greatest  menace  and  that  causes  the 
death,  rather  than  the  mere  withdrawal  of  a  certain  amount  of  blood  from 
the  circulation  at  the  primary  rupture.  This  being  the  case,  the  patient  has  a 
better  chance  of  surviving  the  primary  loss  of  blood  if  simply  kept  quiet 
without  operation,  than  if  operated  on  at  an  inopportune  time  or  without 
reliable  antiseptic  preparation,  or  by  a  person  without  adequate  experience 
in  abdominal  surgery. 

In  most  of  these  cases,  the  hemorrhage  has  ceased  b}"  the  time  the  physi- 
cian reaches  the  patient.  Whether  this  is  the  case  can  be.  determined  with 
a  fair  degree  of  certainty,  as  a  rule,  by  watching  the  patient  for  a  short 
time.  If  the  hemorrhage  has  ceased,  it  Avill  be  seen  that  the  pain  is  dimin- 
ishing and  the  pulse  getting  better.  If  it  is  decided  to  defer  operation  until 
the  patient  has  recovered  from  the  shock  and  the  acute  anemia,  the  patient 
must  be  kept  quiet  in  the  horizontal  posture  absolutely  and  should  make  no 
voluntary  movement;  no  sitting  up,  nor  moving  of  the  extremities  nor  strain- 
ing ;  no  enemata  nor  purgatives.  If  she  is  to  be  moved  to  a  hospital,  it  must 
be  with  practically  no  moi'e  disturbance  than  if  she  Avere  lying  flat  in  bed. 
For  the  first  48  hours  avoid  bowel  movement  if  possible  and  give  very  little 
food.  The  severe  thirst,  caused  by  the  blood  loss,  may  be  relieved  by  small 
doses  of  water,  and  by  saline  solution  per  rectum  by  the  drop  method 
(proctoclysis).     Pain  and  restlessness  are  to  be  relieved  by  sedatives  hypo- 


TEEATMENT  903 

dermieally  or  by  mouth.  Guard  against  vomiting  and  avoid  pelvic  examina- 
tion, for  either  is  very  likely  to  start  up  fresh  hemorrhage.  After  the  first 
two  or  three  days  a  little  more  freedom  may  be  allowed  as  regards  nourish- 
ment, enemata  and  movement  of  arms  and  legs.  But  the  patient  must  main- 
tain the  horizontal  posture  strictly.  The  patient  must  be  especially  warned 
against  straining  in  any  way  and  against  trying  to  sit  up  a  little  because  she 
feels  better.  An  attempt  at  sitting  up  in  bed  may  undo  all  the  good  of  the 
previous  rest,  as  shown  in  the  case  mentioned  on  page  887.  Where  the  hemor- 
rhage has  been  very  severe  it  aWII  usually  require  ten  days  to  two  weeks  for 
the  patient  to  recuperate  sufficiently  to  present  a  good  margin  of  reserve 
force  for  the  operative  work.  With  a  less  abundant  internal  hemorrhage  the 
patient  may  be  in  good  condition  for  operation  within  a  few  days. 

It  must  not  be  forgotten  that  in  these  cases  there  is  always  the  possibility 
of  the  hemorrhage  starting  up  again  suddenly,  in  spite  of  the  care  to  pre- 
vent it.  Consequently,  it  is  always  better  if  the  patient  is  in  the  hospital 
while  waiting  for  her  ''deferred  operation."  Then,  if  renewed  hemorrhage 
develops,  operation  can  be  carried  out  promptly  before  the  patient  again 
passes  into  the  condition  of  extreme  collapse.  These  desperate  cases,  where 
the  vital  forces  are  at  a  low  ebb,  require  much  judgment  and  discrimination 
as  to  when  to  operate  in  a  particular  case  and  as  to  just  what  to  do  at  the 
operation — on  the  one  hand,  to  stop  the  bleeding  and  thus  prevent  the  pa- 
tient from  passing  into  an  absolutely  hopeless  condition,  and,  on  the  other 
hand,  to  avoid  snuffing  out  the  little  spark  of  life  remaining  by  the  added 
strain  of  intraperitoneal  manipulations  and  anesthesia.  The  anesthesia  and 
operative  work  must  be  reduced  to  a  minimum,  both  in  duration  and  extent. 
Some  cases  can  be  satisfactorily  operated  on  under  local  anesthesia,  and  oc- 
casionally there  is  a  case  in  which  the  patient's  sensibilities  are  so  obtunded 
that  practically  no  anesthesia  is  necessary  for  the  work  required. 

By  the  term  "local  anesthesia"  is  meant  a  true  local  anesthesia  (as  in- 
duced by  cocaine  or  eucaine,  or  some  similar  preparation)  and  not  general 
anesthesia  by  hypodermic  injection.  One  must  warn  particularly  against 
the  use  of  scopolamin  (hyoscin)  in  these  cases  where  the  depression  is  so 
marked.  The  induction  of  general  anesthesia  by  hypodermic  injection  of  this 
drug  is  not  the  simple  and  harmless  procedure  one  might  infer  from  the 
tenor  of  the  flood  of  advertising  literature  which  is  being  sent  out  by  a  cer- 
tain interested  commercial  house.  A  number  of  deaths  have  been  caused  by 
the  use  of  this  drug,  and  it  is  especially  dangerous  in  the  serious  conditions 
with  marked  depression.  When  necessary  to  give  something  to  relieve  pain 
or  produce  general  anesthesia  in  the  class  of  cases  under  consideration,  it  is 
better  to  use  some  reliable  drug  the  effect  of  which  is  uniform  and  can  be 
accurately  gauged  and  depended  upon — such  as  morphine  hypodermatically 
or  ether  by  inhalation. 

5.  Pelvic  Hematoma  (Fig.  712).  If  there  are  any  evidences  of  active  or 
recurring  hemorrhage,  the  preferable  treatment  is  abdominal  section,  with 


X--^ 


904  .  -  PELVIC    DISORDERS 

removal  of  the  damaged  tube  and  the  blood-mass.  If  there  is  simply  a  quies- 
cent blood  collection  in  the  connective  tissue,  keep  the  patient  quiet  and 
watch.  If  the  blood-mass  is  gradually  absorbed,  keep  the  patient  quiet  till 
the  mass  has  largely  disappeared,  and  then  she  may  be  allowed  up  and  be 
counted  practically  well.  If  the  mass  remains  stationary  and  symptoms  of 
pronounced  irritation  persist  or  arise  later,  the  patient  should  be  subjected 
to  operation — abdominal  or  vaginal,  as  indicated  by  the  location  of  the  mass 
and  the  accompanying  symptoms. 

6.  Advanced  Cases.  These  cases  vary  so  much  that  it  is  impossible  to 
give  a  rule  applicable  to  all. 

In  some  of  them  immediate  operation  is  indicated,  while  in  others  it  is 
advisable  to  wait  for  a  time,  either  because  the  child  has  only  recently  died 
and  the  placenta  and  adhesions  are  still  dangerously  vascular,  or,  in  rare 
cases,  because  there  is  good  reason  to  hope  for  saving  the  child  without  un- 
justifiable risk  to  the  mother  (Fig.  713). 

OTHER  PELVIC  DISORDERS 

HEMORRHAGE 

When  there  is  hemorrhage  into  the  pelvis  from  any  cause,  if  the  blood 
passes  into  the  peritoneal  cavity,  it  is  known  as  "intraperitoneal  hemor- 
rhage." If  the  amount  of  blood  is  small  and  becomes  shut  in  the  pelvic 
cavity  by  a  roof  of  exudate  and  adhesions  above,  it  is  referred  to  as  a  ''pel- 
vic hematocele."  If  the  blood,  instead  of  passing  into  the  peritoneal  cavity, 
passes  into  the  connective  tissue,  the  resulting  condition  is  called  "pelvic 
hematoma." 

The  usual  cause  of  blood  in  the  pelvis  is  extrauterine  pregnancy,  the  char- 
acteristics of  which  have  just  been  presented. 

Hemorrhage  into  the  pelvis  occasionally  occurs,  however,  from  other 
causes.  A  collection  of  blood  in  the  pelvis,  either  in  the  pelvic  peritoneal 
cavity  or  in  the  connective  tissue,  may  be  caused  by  any  one  of  the  follow- 
ing conditions : 

1.  Rupture  of  a  varicose  vein  of  the  broad  ligament. 

2.  Hemorrhage  from  a  Fallopian  tube,  due  to  inflammation  or  to  a  poly- 
pus, or  some  other  tumor  of  the  tube  (page  908). 

3.  Hemorrhage  from  an  ovary,  due  to  acute  congestion  or  inflammation, 
or  to  a  papillary  growth. 

4.  Rupture  of  one  of  the  dilated  vessels  on  a  large  tumor. 

5.  Hemorrhage  from  injury  due  to  a  blow  or  fall. 

6.  Hemorrhage  from  injury  due  to  forcible  reposition  of  an  adherent 
uterus. 

The  diagnosis  is  made  by  the  same  symptoms  that  indicate  hemorrhage 
in  extrauterine  pregnancy,  but  without  the  evidences  of  pregnancy. 


FULMINATING    PELVIC    EDEMA  905 

As  ill  the  vast  majority  of  cases  of  spontaneous  pelvic  hemorrhage  the 
cause  is  extrauterine  pregnancy,  this  affection  must  be  excluded  in  any  par- 
■  ticular  case  before  any  other  diagnosis  is  permissible.  Sometimes  this  may 
be  excluded  by  the  circumstances  of  the  case — for  example,  the  patient  may 
be  a  virgin,  or  may  be  past  the  menopause,  or  may  have  had  no  recent  op- 
portunity of  becoming  pregnant.  In  some  cases  the  differential  diagnosis 
can  not  be  made  until  the  operation,  when  one  of  the  causes  above  mentioned 
may  be  apparent,  with  absence  of  indications  of  tubal  pregnancy.  In  a 
doubtful  case  the  diagnosis  should  be  reserved  until  the  suspicious  mass,  re- 
m<)ved  at  operation,  has  been  submitted  to  microscopic  examination.  In  a 
tubal  pregnancy,  ruptured  early  and  not  operated  on  for  several  weks,  all 
naked  eye  evidence  of  the  pregnancy  may  disappear.  But  by  microscopic 
examination  of  the  affected  tube,  evidence  of  the  pregnancy  may  be  found. 

The  treatment  of  pelvic  hemorrhage  not  due  to  tubal  pregnancy  de- 
pends on  the  circumstances  of  the  case.  If  the  hemorrhage  is  into  the  con- 
nective tissue  (hematoma)  and  well  circumscribed,  palliative  treatment  only 
is  indicated.  This  consists  of  perfect  quiet  in  the  recumbent  position,  ele- 
vation of  the  foot  of  the  bed  and  an  ice  bag  over  the  abdomen,  and  sedatives 
sufficient  to  give  rest.  In  intraperitoneal  hemorrhage  of  slight  extent,  where 
tubal  pregnancy  can  be  excluded,  the  same  treatment  is  indicated.  In  either 
case  the  effused  blood  may  be  largely  absorbed.  If  after  a  time  it  still  re- 
mains and  gives  trouble  or  suppurates,  the  hematoma  or  hematocele,  as  the 
case  may  be,  has  to  be  opened  from  the  vagina,  emptied  and  packed  with 
gauze,  the  same  as  a  pelvic  abscess. 

If  there  is  serious  intraperitoneal  hemorrhage,  it  requires  abdominal  sec- 
tion, if  the  patient  is  in  fit  condition,  the  additional  steps  in  the  intraabdomi- 
nal treatment   depending  upon   the   conditions   found   within   the   abdomen. 


FULMINATING  PELVIC  EDEMA 

Fulminating  pelvic  edema  is  the  term  applied  to  an  intense  and  wide- 
spread edema  of  the  pelvic  interior,  that  comes  on  suddenly  without  appar- 
ent adequate  cause.  It  is  accompanied  Avith  serious  symptoms  and  usually 
with  extreme  prostration.  In  fact,  the  sudden  onset,  the  severity  of  the 
symptoms  and  the  marked  collapse  suggest  ruptured  tubal  pregnancy,  and 
this  mistaken  diagnosis  has  been  made  in  some  of  the  cases.  It  is  a  rare  con- 
dition and  presents  a  puzzling  problem  in  etiology  and  in  diagnosis.  Most  of 
the  cases  have  been  associated  with  chronic  inflammatory  lesions  in  the  pelvis, 
but  why  the  sudden  edema  and  serious  symptoms  should  develop  without 
apparent  cause  has  not  been  satisfactorily  explained.  Clinically,  however, 
the  condition  must  be  recognized  and  treated ;  hence  its  inclusion  here. 

The  salient  features  in  the  pathology,  symptomatology  and  treatment  of 
this  rare  affection  can  best  be  presented  by  detailing  some  typical  cases. 


906  PELVIC   DISORDERS 

Fulminating  Pelvic  Edema.  I  was  called  in  cousultation  to  see  a  patient  with  pelvic 
disturbance.  It  was  Sunday;  the  patient  had  attended  church  in  the  morning  feeling  fairly 
well,  but  while  there  became  very  sick  and  could  scarcely  get  home.  She  had  a  chill,  fol- 
lowed by  severe  headache  and  general  aching,  but  no  localizing  symptoms.  There  was  no 
apparent  local  trouble  in  any  part  of  the  body  to  account  for  the  fever,  which  rose  to  105.5°. 
By  evening  there  was  evidence  that  the  pelvis  was  the  seat  of  the  disturbance  and  I  was 
asked  to  see  the  patient. 

Examination.  I  saw  her  about  10  p.  m.  The  temperature  had  been  reduced  to  10-4°. 
The  pulse  was  rapid,  but  of  fair  volume.  The  pelvis  was  filled  with  a  tender  mass  which 
surrounded  the  uterus  and  fixed  it  firmly.  There  seemed  to  be  acute  pelvic  inflammation 
with  extensive  exudate.  But  there  was  no  apparent  cause,  either  recent  or  remote.  The 
patient  had  always  been  rather  nervous  and  this  had  been  somewhat  worse  of  late,  but 
there  had  been  no  symptoms  indicating  pelvic  disease  of  any  kind.  The  next  day  the 
temperature  was  104.2°,  pulse  120,  respiration  28,  and  there  was  much  peritoneal  irri- 
tation. Operation  was  at  once  indicated,  to  check  the  rapidly  progressing  inflammation, 
if  possible,  and  accordingly  the  patient  was  taken  to  the  hospital. 

Operation.  WTien  the  abdomen  was  opened  the  pelvis  was  found  filled  with  small 
encysted  collections  of  fluid  involving  the  tubes,  ovaries,  broad  ligament  and  uterus. 
The  cysts  or  pseudocysts  were  of  various  sizes,  were  filled  with  clear  serum  and  seemed 
to  extend  deeply  into  the  substance  of  the  organs  involved.  From  the  appearance  I  sus- 
pected hydatid  disease.  I  removed  all  the  cysts  that  it  was  feasible  to  remove  and  thow 
drained  the  pelvis  through  the  abdominal  incision. 

The  temperature  dropped  within  a  few  hours  to  98°,  and  it  did  not  again  go  high. 
During  the  first  part  of  the  period  of  convalescence  it  ranged  from  99°  to  100.2°,  and 
later  dropped  to  normal,  where  it  remained.  The  wound  and  drainage  tract  healed  rap- 
idly and  the  patient  had  a  smooth  convalescence.  Laboratory  examination  of  the  tissues 
removed  showed  no  bacteria  of  any  kind,  no  evidence  of  hydatid  disease,  and  no  specific 
pathologic  process  that  would  adequately  account  for  the  alarming  symptoms  and  the 
marked  tissue  change. 

Fulminating  Pelvic  Edema.  Reported  by  Briggs.  A  married  woman,  whose  men- 
struation had  been  normal,  came  complaining  of  malaria  and  some  pelvic  pain.  Pelvic 
examination  showed  nothing  abnormal  except  a  slight  fullness  about  the  left  adnexa.  Two 
days  later  the  patient  returned  to  the  office,  very  sick.  Her  face  was  pale  and  pinched 
and  anxious;  pulse  320,  small  and  weak;  temperature,  100°.  The  pelvis  was  then  com- 
pletely filled  with  a  fluctuating  mass.  The  rapid  development  of  the  mass,  with  almost  no 
fever,  pointed  to  hemorrhage  as  the  cause,  and  a  diagnosis  of  tubal  pregnancy  was  made. 
At  the  operation,  the  pelvis  was  found  filled  with  small  cysts  of  various  sizes,  formed  by 
collections  of  serum  within  the  connective  tissue.  There  was  no  tubal  pregnancy.  The 
pelvis  was  drained  and  the  patient  recovered. 

Fulminating  Pelvic  Edema.  Reported  by  Briggs.  Patient's  menstruation  was  de- 
layed four  days,  then  came  on  scanty  and  was  accompanied  by  paroxysmal  pains,  which 
caused  the  patient  to  think  she  was  having  a  miscarriage.  After  some  days  the  pain 
became  more  severe  and  the  patient  had  two  fainting  spells.  Temperature  was  normal, 
pulse  90  and  small  and  compressible.  The  abdomen  was  sensitive.  Sedatives  were  given, 
which  diminished  the  pain,  but  the  shock  increased.  Tlie  radial  pulse  became  imperceptible 
and  the  skin  and  mucous  membranes  were  markedly  anemic.  The  uterus  was  enlarged, 
retroverted,  fixed  and  sensitive,  adnexa  not  felt.  Liquid  could  be  demonstrated  in  the 
flanks.     Diagnosis,  tubal  pregnancy  with  rupture. 

Operation.  The  pelvis  and  lower  abdomen  were  filled  with  great  blebs  due  to  the  col- 
lection of  serum  in  the  connective  tissue,  causing  the  peritoneum  to  pouch  into  the  pelvis 
from  all  directions.  Both  tubes  were  chronically  inflamed  and  the  right  ovary  was  enlarged 
and  cystic. 

The   patient's  condition   continued   bad   and   she   died   some  hours   after   the   operation. 


TUMORS    OP    FALLOPIAN    TUBES 


907 


The  feature  of  the  case  was  the  enormous  amount  of  serum  pocketed  in  the  connective 
tissue,  without  any  evidence  of  recent  inflammation. 

Fulminating  Pelvic  Edema.  Eeported  by  Legueu.  Shortly  after  a  normal  men- 
struation, patient  was  suddenly  attacked  with  violent  pelvic  pain  accompanied  by  syncope, 
extreme  pallor  and  cold  extremities.  The  abdomen  was  distended,  hard  and  painful  to 
pressure.  Vaginal  examination  disclosed  a  fluctuating  mass  in  the  cul-de-sac.  Diagnosis, 
retrouterine  hematocele.  On  opening  the  abdomen  a  quantity  of  yellow  serum  escaped. 
There  were  large  collections  of  serum  in  the  tissues  about  the  right  adnexa,  aggregating 
a  pint.  The  patient  recovered.  Examination  of  the  serum  showed  only  leukocytes  and 
peritoneal  cells. 

Fulminating  Pelvic  Edema.  Reported  by  Jocet.  Patient,  aged  28,  married  eight 
years,  no  children,  had,  on  three  separate  occasions,  an  attack  of  severe  abdominal  pain 
accompanied  by  an  accumulation  of  fluid  in  the  right  iliac  fossa,  which  presented  the  char- 
acteristics of  hematocele.  Twice  the  mass  terminated  by  resolution  and  the  patient  was 
perfectly  well  in  the  intervals.  The  third  time,  after  the  usual  symptoms  of  the  supposed 
hematocele  had  continued  some  weeks  with  improvement,  the  patient  was  suddenly  seized 
with  violent  abdominal  pain,  accompanied  by  pallor,  anxious  facies,  and  incessant  vomiting. 
Tlie  mass  enlarged  and  there  developed  features  that  pointed  to  inflammation  rather  than 
hemorrhage  as  the  cause  of  the  trouble.  Operation  showed  the  pelvis  filled  with  encysted 
collections  of  serum,  and  finally,  deep  in  the  j^elvis,  there  was  found  an  old  ovarian  ab- 
scess,  which   was   evidently   the   exciting   cause   of   the   surrounding  edema. 


TUMORS  OF  FALLOPIAN  TUBES 

Primary  tumors  of  the  Fallopian  tubes  are  very  rare.    Fibromyoma,  car- 
cinoma, and  sarcoma  may  occur  here,  and  they  present  the  same  structure 


Fig.   714.      Sarcoma  of  a  Fallopian   Tube,   second- 
ary to  a  sarcoma  originating  in  a  uterine  fibromyoma. 


Fig.  715.  Sarcoma  of  a  Fallopian  Tube,  show- 
ing, under  high  power,  the  sarcomatous  infiltration 
of  the  tubal  mucosa- 


908 


PELVIC    DISORDERS 


and  tendencies  as  elsewhere.  Secondarily,  sarcoma  may  develop  in  the  tubal 
mucosa  in  instances  of  uterine  sarcoma,  as  shown  in  Figs.  714  and  715. 

K  arising  from  the  interstitial  portion  of  the  tube,  they  produce  the 
symptoms  of  similar  tumors  of  the  uterus.  If  arising  from  the  outer  portion 
of  the  tube,  they  correspond  in  position  to  tumors  of  the  ovary. 

It  is  interesting  to  note  that  chorioepithelioma  has  been  found  in  a  tube 
following  tubal  pregnancy. 

The  diagnosis  of  tumors  of  the  tube  is  usually  made  after  the  abdomen  is 
opened.  They  present  no  definite  distinguishing  characteristics,  and  when 
felt  in  examination  are  usually  taken  for  growths  arising  from  those  struc- 
tures in  which  tumors  more  frequently  occur ;  namely,  the  uterus,  the  ovary 
or  the  broad  ligament. 

The  treatment  for  tumors  of  the  tube  is  the  same  as  for  like  growths  in 
other  pelvic  organs. 


VARICOSE  VEINS  OF  BROAD  LIGAMENT 

Occasionally  the  veins  of  the  broad  ligament  are  found  markedly  dilated, 
and  in  the  dilated  veins  are  sometimes  found  thrombi  and  even  small  stones 
(phleboliths). 

The  principal  etiologic  factors  of  these  varicosities  are  subinvolution  of 
the  broad  ligaments  folloAving  pregnancy,  relaxation  of  the  tissues  from  poor 


.    Fig.   716.      Ligating   Varicose   Veins   in   the    Broad    I^igament.      (Reed — Textbook   of   Gynecology.') 

general  health,  and  obstruction  of  the  venous  circulation  of  the  broad  liga- 
ment by  tumors,  or  by  heart  disease,  or  by  loaded  bowel,  or  by  uterine 
displacement. 

The  symptoms  (Aveight  and  pressure  when  upright  and  relieved  by  the 
recumbent  posture)  are  not  distinctive — in  fact,  the  condition  is  usually  over- 
shadowed by  more  evident  lesions.  In  most  cases  so  far  reported  this  con- 
dition was  thought  of  only  after  the  abdomen  was  open  and  the  enlarged 
veins  were  apparent. 

In  cases  of  persistent  pelvic  pain  without  palpable  lesion,  this  condition 
should  be  thought  of,  and  if  the  symptoms  are  severe  in  spite  of  palliative 


PSEUDOTUBERCTJLOSIS    OP    PERITONEUM  909 

measures  it  may  be  advisable  to  make  an  exploratory  abdominal  section, 
with  the  idea  of  correcting  this  condition  if  found. 

When  phleboliths  or  thrombi  (Fig.  382)  are  present,  they  may  in  excep- 
tional cases  form  masses  that  can  be  felt  on  bimanual  palpation. 

The  treatment  is  abdominal  section  and  ligation  of  the  enlarged  veins 
at  short  intervals,  as  advocated  by  Reed  (Fig.  716),  and  free  incision  and 
evacuation,  of  the  ligated  portions. 

ECHINOCOCCUS  DISEASE  OF  PELVIS 

Echinoeoccus  disease  is  occasionally  found  in  the  pelvis.  For  a  descrip- 
tion of  this  affection  see  Echinoeoccus  Disease  of  the  Uterus  (page  666).  When 
it  affects  other  pelvic  structures,  it  is  supposed  in  most  cases  to  come  from  the 
rectum  by  way  of  the  perirectal  connective  tissue. 

PSEUDOTUBERCULOSIS  OF  PERITONEUM 

This  is  a  rare  condition,  in  which  the  pelvic  peritoneum  is  studded  with 
small  opaque,  thickened  spots,  presenting  the  superficial  appearance  of  peri- 
toneal tuberculosis.  Microscopic  examination  of  the  involved  tissue,  however, 
shows  no  tuberculosis,  but  simply  chronic  inflammatory  infiltration. 


CHAPTER  XII 

TUMORS  OF  THE  OVARY  AND  PAROVARIUM 

Before  taking  up  the  tumors  of  the  ovary  and  parovarium,  the  author  wishes 
to  call  attention  to  certain  points  in  the  anatomy  and  physiology  of  the  structures 
involved. 

POINTS  IN  ANATOMY  AND  PHYSIOLOGY 

THE  OVARY 

The  ovaries  are  situated  one  on  either  side  of  the  uterus  near  the  pelvic 
brim  and  close  to  the  outer  end  of  the  Fallopian  tube  (Figs.  3,  4).    Each  ovary 


Fig.  717.  X'ertical  Section  through  the 
Dread  Ligament,  showing  the  Relation  of 
the  Ovary  to  the  same.  5,  Fallopian  tube. 
6,  Round  ligameiit.  /,  Ovary.  7',  Meso- 
varium,  connecting  the  ovary  with  the  broad 
ligament.  (Jewett,  from  Testut — Practice 
of   Obstetrics.) 


Fig.  71 S.  Section  of  the  Ovary  of  a  Cat.  1,  Peritoneal 
surface  of  the  ovary.  /,  Hilum.  2,  Medullary  portion  of 
ovary,  s.  Cortical  portion.  5,  Small  Graafian  follicles.  -,  8,  9, 
Maturing  Graafian  follicles.  10,  Corpus  luteum.  (Jewett, 
after    Schoen — Practice    of    Obstetrics.) 


910 


ANATOMY  AND   PHYSIOLOGY 


911 


projects  from  the  posterior  wall  of  the  broad  ligament  of  its  respective  side 
and  the  peritoneal  fold  thus  formed  is  called  the  ''mesovarium"  (Fig.  717). 

It  is  through  this  attachment  to  the  broad  ligament  that  the  ovary  receives 
its  blood  supply,  this  being  the  point  where  the  vessels  enter. 

The  shape  of  the  ovary  is  much  like  that  of  an  almond.  In  size  the  ovaries 
vary  much  in  different  individuals,  and  even  in  the  same  individual  the  two 
ovaries  may  differ  in  size.  Ordinarily  the  ovary  is  li/^  to  2  inches  in  length, 
about  1  inch  in  width,  and  about  1/2  inch  in  thickness.  It  weighs  75  to  150 
grains. 

Structure.    In  structure  the  ovary  is  simply  a  bunch  of  ova,  or  microscopic 


F 


in^p^H*V|.iMl^r«jj|^4iu<^^.w»'. 


-#- 


"^JSf* 


_ ^,^ 


Fig.   719.     A    Graafian    Follicle.      Notice    that    the    section    cuts    the    lateral    portion    of    the    ovum    (and    thus 

identifies    it)    but   misses   the   nucleus. 


eggs,  supported  and  held  together  by  the  connective  tissue  which  forms  the 
frame-work.  Each  ovum  is  contained  within  a  minute  sac,  called  the  ovisac 
or  Graafian  follicle  (Fig.  718).  The  connective  tissue  extends  betAveen  the  fol- 
licles in  all  directions,  and,  in  addition  to  supporting  and  protecting  them,  it 
carries  the  blood  vessels  that  nourish  them  and  also  the  lymph  vessels  and 
nerves.  This  connective  tissue  constitutes  the  ovarian  stroma  and  it  is  peculiar 
in  that  it  is  exceedingly  rich  in  cells  (Fig.  722).  These  are  spindle-shaped  con- 
nective tissue  cells,  and  they  are  packed  so  closel}^  together  that  in  an  ordinary 
microscopic  preparation  the  tissue  seems  to  be  made  up  exclusively  of  long,  oval 
nuclei  lying  close  together  (Figs.  719  and  720).  Near  the  periphery  of  the 
ovary  the  connective  tissue  fibers  become  more  numerous  and  the  nuclei  fewer. 


912  TUMORS    OF    THE    OVARY    AND    PAROVARIUM 

SO  that  there  is  here  a'rather  dense  capsule.  This  fibrous  capsul.  ot  'tie  ovary 
is  known  as  the  "tunica  albuginea. "  It  is  simply  a  condensation  oi  ^L?.  ovarian 
stroma  and  serves  to  protect  the  deeper  structures  of  the  ovary.  Outside  of 
this  fibrous  layer  lies  the  epithelial  covering. 

That  portion  of  the  ovary  at  which  the  vessels  find  entrance  a^-  exit  is 
called  the  hilum  (Fig.  718).  Immediately  about  the  hilum,  and  +ending 
some  little  distance  into  the   ovary,  is  the  area   known  as  the    i 

T  ex.  T  irt 


W,^  1   -^  y  ^  '-^  *  ^  '^.^    ^.^J". 


i  f   «  4Pt%^3        t,^     «i  ^' «.'««»*  «*  Jfe*.-*^  *V-    fc'^ 


Fig.   720.     A   Graafian    Follicle   with   its   Contained    Ovum,    highly   magnified.      M.    G.,    membrana    gra 
The   ovarian   stroma  is   also   well   shown.      (Williams — Obstetrics.) 

medullary  portion.     This  is  occupied  by  the  blood  vessels,  lymph  vessels,  . 
nerves  and  supporting  coimective  tissue.    It  contains  no  follicles. 

The  remaining  part  of  the  ovary  contains  the  Graafian  follicles,  ^-ad  is 
called  the  cortex  or  cortical  portion  (Fig.  718).  The  free  surface  of  the  cor- 
tical portion — that  is,  the  peritoneal  surface  of  the  ovary — is  covered  with 
cylindrical  epithelium,  the  remains  of  the  germinal  epithelium,  from  which 
the  ova  and  Graafian  follicles  were  formed  by  infoldings  (Fig.  721). 

The  Graafian  follicles  are  very  numerous  and  of  different  sizes.  The  small 
young  follicles  lie  near  the  surface  and  number  thousands.  They  are  about 
1/100  of  an  inch  in  diameter  (Fig.  7-22).    The  larger,  older  follicles  lie  deeper 


ANATOMY   AND   PHYSIOLOGY 


913 


TS'^x/* 


^.   721.     Development   of   the   Ovary    (after   Wiederslteim).     A,   an   ingrowth   of   the   germinal   epi- 
.^Ji .,  rogffiing  a  cell-cord,  which  breaks  up  into  primitive  Graafian  follicles;  B,  a  primitive  Graafian  follicle, 
Afith  it;-^soat-ained  primitive  ovum;  C,  D,  E,  later  stages  in  the  development  of  the  Graafian  follicle. 


*JSt; 


Fig.   722.     Ovarian  stroma  and  five  immature   follicles. 


914 


TUMORS   OF    THE   OVARY   AND   PAROVARIUM 


and  are  not  so  numerous.  The  largest  of  these  measure  1/25  of  an  inch  in 
diameter. 

The  Graafian  follicle  is  lined  with  an  epithelial  layer  several  cells  thick, 
called  the  "membrana  granulosa,"  and  is  filled  with  clear  viscid  fluid,  the 
"liquor  folliculi."  The  ovum  lies  within  the  follicle  near  one  side  and  is  com- 
pletely surrounded  by  cells  of  the  membrana  granulosa  (Fig.  720). 

As  the  Graafian  follicle  matures,  it  again  approaches  the  surface  and  be- 
comes still  larger.     It  gradually  protrudes  at  the  free  surface  of  the  ovary 


Corpus       ,  £i 


Fig.  723.     A   Corpus   I^uteum,    fifteen  days   from  Fig.  724.     Ovary    of    a    Virgin,    showing   an    un- 

the   beginning   of   menstruation.      (Baldy — American        usually   large   corpus   Inteum.      Notice   what   a  large 
Textbook    of   Gynecology.)  part  of  the  ovary  the  corpus  luteum  occupies.     (Pier- 

sol,  after  Hirst — American  Textbook  of  Obstetrics.^ 


C.F  -/  — 


H-K 


Fig.   725.      Section    of    a    Corpus    Luteum,    showing    the    wavy    line    composed    of    lutein    cells.      (Williams — 

Obstetrics.) 


ANATOMY   AND   PHYSIOLOGY 


915 


Fig.  726.  Ovarian  Stroma  (under  low  power), 
showing  part  of  a  corpus  luteum  in  right  lower 
corner. 


Ij     «  a 


i     «e    ^    cc;..        /^■^,Ak^*^,    /.ill      ^      '    '     - 


Fig.  728.  Shows,  under  high  power,  the  char- 
acteristic large  pale  lutein  cells  lying  closely  along 
the   thin-walled   newly  formed  blood  vessels. 


Fig.  727.  The  Wavy  Line  in  the  Wall  of  the 
Corpus  Luteum,  highly  magnified  to  show  the  lutein 
cells.      (Williams — Obstetrics.) 


■if" 


-i3 


Fig.   729.     The    early    stage    of    development    of    the 
corpus    albicans,    low   power. 


916  TUMORS    OF    THE   OVARY   AND   PAROVARIUM 

and  when  ripe  it  bursts,  liberating  the  ovum  on  the  surface  of  the  ovary,  from 
where  it  finds  its  way  into  the  Fallopian  tube.  This  ripening  and  bursting  of 
the  Graafian  follicle  and  liberation  of  the  contained  ovum  is  called  ''ovula- 
tion," and  usually  precedes  menstruation  by  approximately  ten  to  twelve  days. 

After  the  ripened  ovum  is  discharged,  the  ruptured  follicle  fills  with 
bloody  serum,  v/hich  clots.  The  rent  in  the  follicular  wall  soon  heals  and  the 
blood  clot  becomes  partially  decolorized.  This  follicle,  filled  with  blood  clot, 
is  very  prominent  (Figs.  723,  724)  and  w^hen  encountered  during  the  course 
of  an  operation  has  been  mistaken  for  hematoma  of  the  ovary,  though  it  is 
simply  a  recently  ruptured  follicle  and  consequently  a  normal  structure. 

In  a  few  days  there  appear  certain  peculiar  cells  containing  pigment. 
These  cells  are  large,  resembling  decidua  cells.  They  are  formed  first  about 
the  periphery  of  the  fibrinous  mass,  but  they  gradually  increase  in  number  and 


■^ 


^\  >:  -  ::  _  '^  ^   ._  ^? 


i 


Ji      'ill.  ^-  ■-  r      ^  *^  „     ^^ 

Fig.  730.  The  Corpus  Albicans.  After  the  ruptured  follicle  has  passed  through  the  various  stages 
of  the  corpus  luteum,  there  remains  simply  a  wavy  line  of  fibrous  tissue,  representing  the  final  stage  of  the 
ruptured  follicle.  The  retraction  of  this  scar-tissue  causes  depressions,  as  shown  in  Fig.  731.  (Williams — 
Obstetrics.) 

advance  toward  the  center,  until  finally  they  fill  nearly  the  whole  interior 
of  the  broken  follicle  (Figs.  725,  726,  727).  The  pigment  in  the  cells  is  yellow; 
consequently  they  are  called  ''lutein"  cells,  and  the  mass  formed  by  them  is 
of  course  also  yellow  and  hence  is  called  the  corpus  luteum  (yellow  body).  A 
section  of  a  corpus  luteum  shows  a  wavy  yellow  outer  portion  formed  by  the 
lutein  cells  (Figs.  723  and  727).  Under  high  power  they  can  be  seen  lying 
closely  along  the  thin- walled,  newly  formed  blood  vessels  (Fig.  728).  It  is 
this  picture,  characteristic  of  the  structure  of  endoerin  glands,  which  fur- 
nishes strong  proof  for  the  internal  secretion  function  of  the  corpus  luteum 
(see  Chapter  xv) .  The  source  of  these  lutein  cells  is  still  in  dispute.  Most 
authorities  hold  that  they  are  derived  from  the  remnants  of  the  membrana 
granulosa,  while  others  state  that  they  are  developed  from  the  connective  tis- 


ANATOMY   AND   PHYSIOLOGY 


917 


sue  cells  of  the  "tlieca  interna''  (the  internal  layer  of  the  fibrous  capsule  of 
the  Graafian  follicle). 

The  lutein  cells  gradually  disappear  and  after  a  time  the  area  of  the 
ruptured  follicle  is  occupied  only  by  scar-tissue  (Fig.  730).  The  area  is  then 
no  longer  yellow,  but  white,  and  consequently  is  called  the  corpus  albicans 
white  body)  (Figs.  729,  730).  The  corpus  albicans,  consisting  of  scar-tissue 
represents  the  final  stage  of  the  ruptured  follicle.  After  many  follicles  have 
ruptured,  the  surface  of  the  ovary  often  becomes  very  uneven  on  account  of 
the  number  of  these  depressed  scars  (Fig.  731). 

Ordinarily  the  corpus  luteum  passes  through  the  changes  described  in  a 
short  time.     If,  however,  pregnancy  follows  ovulation,  the  corpus  luteum  of 


,--'" 

— — •- 

Append 

vcsicul 

£IorgagniQ\ 

w 

Fimhria 
ovarica 

'C 

i 

i 

!\t 

j 

/ 


Fig.  731.  The  Ovary  of  a  Woman  Twenty-three 
Years  of  Age.  Notice  the  depressed  scars,  resulting 
from  ruptured  follicles.  (Piersol,  after  Sutton — 
American   Textbook   of  .Obstetrics.) 


Duct  of 

Mueller 


Parovarian 

remains 
Parovarium 

(Epooplioron) 


Pcroophoroii 


Duct  of 

MuciiGr 


uterus 

—   Duct  of 

Cartncr 


Fig.  732.  Embryonic  Genital  Organs,  showing 
the  parovarium  and  paroophoron,  and  their  relation 
to  the  tube  and  ovary  and  duct  of  Gartner.  (Abel, 
after   Kollmann — Gynecological   Pathology.) 


that  ovulation  groAvs  very  large  and  remains  for  months  before  retrograde 
changes  set  in. 

Ligaments.  The  ovary  lies  in  the  pelvis  obliquely  and  its  inner  end  is 
about  one  inch  from  the  uterus.  Extending  from  this  end  of  the  ovary  to  the 
uterus  is  a  small  fibro-muscular  cord,  the  ''utero-ovarian  ligament,"  which 
joins  the  uterus  just  below  the  Fallopian  tube  (Fig.  4).  The  suspensory  liga- 
ment of  the  ovary,  the  ''ligamentum  suspensorium  ovarii,"  is  the  thickened 
edge  of  the  broad  ligament  connecting  the  ovary  and  tube  Avith  the  side  of 
the  pelvis.  The  "infundibulo-ovarian  ligament"  extends  from  the  ovary  to 
the  outer  end  of  the  Fallopian  tube. 

Vessels  and  Nerves.    The  ovary  is  supplied  with  blood  by  several  branches 


918  TUilOES    OP    THE    OVAEY   AXD    PAKOVARIUM 

of  the  ovarian  artery,  which  corresponds  to  the  spermatic  artery  in  the  male. 
The  ovarian  artery  arises  directly  from  the  abdominal  aorta  and,  passing 
downward  to  the  side  of  the  pelvis,  enters  the  broad  ligament  and  sends 
branches  to  the  ovary  and  nterus  and  tnbe.  The  veins  correspond  to  the  artery 
and  form  a  plexus  near  the  hilum.  which  is  known  as  the  pampiniform  plexus, 
sometimes  called  the  ovarian  plexus. 

The  lymphatic  spaces  siu'roiind  the  Graafian  follicles  and  ramify  through- 
out the  connective  tissue  of  the  ovary.  They  pass  out  at  the  hilum  and  anasto- 
mose with  the  uterine  lymphatics  in  the  broad  ligament  and  empty  into  the 
lumbar  glands. 

The  nerves  come  from  the  renal  and  spermatic  ganglia.  The  fibers  pass 
along  in  the  connective  tissue  framework  to  all  the  Crraafian  follicles  and 
terminate  in  the  follicular  epithelium. 

Physiology  of  the  Ovary.  The  principal  function  of  the  ovary  is  the  for- 
mation of  ova.  The  ova  are  developed  from  primitive  ova  derived  from  the 
"germinal  epithelium"  of  the  embryo.  In  the  formation  of  the  ovary  in  the 
growing  embryo,  portions  of  the  germinal  epithelium  are  included  within  the 
organ,  and  from  these  included  cells  the  ova  and  Crraafian  follicles  are  de- 
veloped (Fig.  721).  A  remnant  of  the  primary  germinal  epithelium  remains. 
as  the  layer  of  cylindrical  epithelium  covering  the  peritoneal  surface  of  the 
ovary.  In  the  preparation  of  ova,  Xature  displays  a  lavish  hand.  It  is  esti- 
mated that  each  ovary  at  the  age  of  eighteen  years  contains  36.000  ova.  but 
not  more  than  200  of  these  reach  maturity. 

The  ovum,  which  is  the  most  important  structure  in  the  ovary,  is  a  single 
cell  composed  of  four  parts,  as  follows: 

a.  A  thick  surrounding  substance   or  membrane   called  the   "zona 
radiata"  or  zona  pellucida. 

b.  The  cell  substance  or  protoplasm,  the  inner  portion  of  which  is 
kno^nm  as  the  'Sutellus." 

c.  The  nucleus  or  "germinal  vesicle." 

d.  The  nucleolus  or  "germinal  spot." 

The  ovum  is  spherical,  and  when  fully  developed  measures  ^120  of  an  inch 
in  diameter.  Just  before  the  orwrn  is  discharged  upon  the  surface  of  the  ovary 
by  the  bursting  of  the  follicle,  as  previously  described,  it  goes  through  a  process 
of  ripening.  This  process  is  called  "maturation"  and  consists  in  the  karyo- 
kinetic  division  of  the  nucleus  and  the  expulsion  of  a  small  portion  of  it.  This 
occurs  twice  in  succession.  The  cast  off  portions  have  been  named  "polar 
bodies."  The  polar  bodies  are  apparently  of  no  further  use,  as  they  soon  dis- 
appear. It  may  be  remarked  here  that  certain  tumors  (teratomata)  are  sup- 
posed to  origmate  from  these  polar  bodies.  The  remains  of  the  nucleus  wander 
to  near  the  center  of  the  cell  and  the  ovum  assumes  a  resting  state.  It  is  then 
ready  for  impregnation.  It  is  carried  into  the  Fallopian  tube,  and,  if  impregna- 
tion does  not  take  place,  passes  into  the  uterus  and  out  of  that  organ  into  the 
vagina  and  is  lost. 


ANATOMY   AND   PHYSIOLOGY  919 

In  recent  years  it  has  come  to  be  recognized  that  the  ovary  has  another 
function,  entirely  distinct  from  ovulation.  This  is  known  as  the  trophic  func- 
tion or  endocrin  function  of  the  ovary.  By  clinical  observations  and  by 
experiments  on  animals  the  following  facts  have  been  established. 

1.  That  the  ovary  controls  menstruation.  When  the  ovaries  are  removed, 
menstruation  soon  ceases.  The  ovary  furnishes  the  "menstrual  impulse," 
though  the  menstrual  blood  itself  comes  from  the  uterus. 

2.  That  the  ovary  controls  the  development  of  the  uterus  and  of  the 
breasts.  When  the  ovaries  of  newly-born  guinea  pigs  were  removed,  the 
breasts  and  the  uterus  and  even  the  external  genitals  failed  to  develop.  When 
one  ovary  Avas  left,  the  normal  development  took  place  the  same  as  though 
both  ovaries  were  present.  Similar  experiments  on  rabbits  and  on  dogs  gave 
identical  results ;  i.  e.,  the  removal  of  both  ovaries  in  the  young  prevented 
proper  development  of  the  uterus  and  the  breasts. 

3.  That  the  ovary  controls  to  a  considerable  extent  the  nutrition  of  the 
uterus,  even  in  the  adult.  Numerous  experiments  in  rabbits  and  dogs  and 
cows  have  shown  that  after  the  removal  of  both  ovaries  the  uterus  slowly 
atrophies  and  develops  the  characteristics  of  senility.  Clinical  experience  and 
pathologic  investigation  have  shown  that  the  same  results  slowly  take  place 
in  women  after  the  removal  of  both  ovaries. 

'4.  That  the  ovary  exercises  a  decided  influence  on  the  nervous  system. 
In  very  many  cases  after  the  complete  removal  of  the  ovaries  there  appear 
certain  nervous  disturbances.  These  are  practically  the  same  as  are  found 
accompanying  the  natural  menopause — hot  flashes,  fleeting  emotional  disturb- 
ances and  other  evidences  of  an  unstable  or  irritable  nervous  system.  These 
occur  so  regularly  after  double  oophorectomy  that  Ave  expect  them,  and  give 
to  the  symptom  group  the  name  ' '  artificial  menopause ' '  or  induced  menopause. 
These  symptoms  usually  subside  after  one  or  tAvo  or  three  years,  as  in  the 
natural  menopause.  Occasionally,  hoAvever,  they  persist  and  increase  and  be- 
come serious.  If  one  ovary  be  left,  or  even  part  of  an  ovary  that  continues 
to  functionate,  these  symptoms  do  not  appear,  shoAving  that  the  ovary  exercises 
the  controlling  influence.  If  still  stronger  proof  of  this  fact  be  desired,  it  is 
found  in  this:  In  patients  suffering  Avith  these  troublesome  symptoms  foUoAV- 
ing  removal  of  both  ovaries,  healthy  ovaries  have  been  transplanted,  Avith  the 
result  that  the  symptoms  under  consideration  entirely  disappeared,  at  least 
temporarily. 

NoAV  comes  the  question,  how  does  the  ovary  exercise  this  marked  trophic 
influence,  CAddenced  (1)  by  controlling  menstruation,  (2)  by  controlling  the 
development  of  the  uterus  and  breasts,  (3)  by  controlling  the  nutrition  of  the 
uterus  and  (4)  by  controlling  certain  nervous  disturbances?  It  Avas  supposed 
for  a  long  time  that  the  influence  Avas  reflex,  by  Avay  of  the  nerves  in  the  ovary. 
But  it  is  noAv  pretty  Avell  established  that  it  is  not  by  the  nerA^es,  but  by  some 
substance  Avhich  is  manufactured  in  the  OA^ary  and  throAAai  into  the  circulating 
blood.     This  action  is  designated  by  the  term  ''internal  secretion."     It  is 


920  TUMORS    OF    THE   OVARY   AXD   PAROVARIUIM 

analogous  to  tlie  fiuietioii  of  the  tlivroicl  gland,  wMcli,  tliougli  it  possesses  no 
duct,  manufactures  a  principle  which  finds  its  Avay  into  the  circulation  and 
exercises  a  marked  influence  over  the  general  nutrition,  as  evidenced  by  the 
fact  that  Tvhen  the  thyroid  gland  is  destroyed  by  disease  or  operation,  there 
results  that  very  serious  condition  known  as  myxedema.      (See  Chapter  xv). 

That  the  powerful  trophic  influence  of  the  ovary  is  due  to  an  internal  secre- 
tion into  the  circulation,  and  not  to  reflexes  through  the  ovarian  nerves,  is 
indicated  by  the  fact  that  if  the  ovaries  be  removed;  i.  e.,  entirely  severed  from 
their  nervous  connections,  and  transplanted  to  another  part  of  the  body — ^they 
still  exercise  the  same  influence.  This  has  been  demonstrated  over  and  over 
again  by  various  authorities.  In  guinea  pigs  the  ovaries  Avere  removed  from 
the  pelvis  and  transplanted  under  the  skin,  with  the  result  that  the  uterus 
and  breasts  developed  normally.  As  the  ovaries  had  been  entirely  severed 
from  the  pelvic  nerves,  the  only  possible  way  for  them  to  influence  the  uterns 
and  breasts  was  through  the  circulation.  In  rabbits  and  dogs  transplantation 
of  the  ovaries  to  various  parts  of  the  body  has  given  similar  results. 

In  the  human  patient  transplantation  of  an  ovary  from  one  patient  to 
another  has  been  successfully  carried  out  a  few  times  and  with  decidedly  bene- 
ficial results.  There  is  not  space  to  go  further  into  the  interesting  experiments 
along  this  line.  Enough  has  been  said  to  show  that  the  ovary  has  two  im- 
portant functions,  (1)  the  formation  of  the  ova  suitable  for  impregnation 
and  (2)  the  nutritional  effect  (probably  due  to  the  internal  secretion  into  the 
circulation  of  some  substance),  by  Avhich  is  exercised  a  controlling  influence 
on  menstruation,  on  the  development  of  the  uterus  and  breasts,  and  on  certain 
nervous  disturbances. 

Based  on  the  latter  function  of  the  ovary  are  certain  therapeutic  measures 
which  have  come  into  prominence  in  the  last  few  years.    They  are  as  follows: 

1.  Leaving'  Part  of  an  Ovary.  In  the  operative  treatment  of  ovarian  dis- 
eases, an  ovary  or  part  of  an  ovary  is  always  preserved  in  place  if  the  patho- 
logic condition  will  permit. 

2.  Administration  of  Ovarian  Extract.  If  both  ovaries  must  be  sacriflced, 
the  patient  is  afterwards  given  ovarian  extract  for  the  purpose  of  lessening  the 
disturbances  of  the  artificial  menopause.     (See  Chapter  xv.) 

3.  Transplantation  of  an  Ovary.  In  a  patient  presenting  serious  symptoms 
as  the  result  of  the  removal  of  both  ovaries  by  operation  or  their  destruction 
by  disease,  a  healthy  ovary  from  another  person  is  transplanted  to  the  pelvis 
of  the  chronic  invalid  to  supply  again  the  ovarian  trophic  substance. 

This  has  been  carried  out  successfully  in  several  instances.  In  one  patient 
the  transplantation  operation  was  made  two  years  after  both  ovaries  had 
been  removed.  The  patient  was  restored  to  health  and  there  was  also  partial 
restoration  of  the  menses.  Still  better  results  have  followed  the  immediate 
transplantation  of  a  healthy  ovary  during  the  primary  operation  in  which 
both  ovaries  were  so  diseased  that  they  had  to  be  removed.  In  at  least  one 
case  the  menstruation  continued  regularly  as  though  the  ovaries  had  not  been 


ANATOMY   AND   PHYSIOLOGY 


921 


disturbed.  This  work  is  still  in  the  experimental  stage,  but  enough  has  already 
been  accomplished  to  show  that  a  healthy  ovary,  successfully  transplanted,  can 
continue  its  functions,  at  least  for  a  limited  time,  and,  consequently,  that  many 
women  can  be  rescued  from  the  condition  of  chronic  invalidism  caused  by 
destruction  of  the  ovaries  or  by  imperfect  development  of  the  same. 

Investigations  concerning  the  trophic  influence  of  the  ovary  indicate  that 
this  influence  comes  from  the  corpus  luteum.  In  fact  it  appears  that  the 
corpus  luteum  is  a  temporary  secreting  gland,  the  lutein  cells  being  the  active 
secreting  cells.    In  support  of  the  theory  that  it  is  the  secretion  of  the  lutein 


Fig.   733.     Adult  Genital   Organs   showing  parovarium,    Gartner's   duct   and   various   other   structures.      (Kelly 

after  Cullen — Operative  Gynecology.) 


cells  that  controls  menstruation  and  exercises  the  general  trophic  influence  due 
to  the  ovary,  the  following  facts  have  been  cited: 

a.  In  the  transplantation  experiments  previously  mentioned,  if  the  trans- 
planted ovary  did  not  survive  in  such  condition  that  ovulation  took  place ;  i.  e., 
an  ovum  was  discharged  and  a  corpus  leuteum  formed— no  trophic  influence 
was  apparent.    It  was  just  as  though  no  ovarian  tissue  were  present. 

b.  Destruction  of  the  corpus  luteum  in  rabbits  in  the  early  part  of  preg- 
nancy prevented  complete  development  of  the  pregnant  uterus  and  contained 


922  TUMORS   OF   THE   OVARY   AND   PAROVARIUM 

ovum.     The  effect  was  the  same,  whether  the  entire  ovary  was  removed  or 
simply  the  corpus  luteum  destroyed. 

c.  Destruction  of  the  corpus  luteum  in  the  non-pregnant  caused  the  next 
menstruation  to  be  missed,  indicating  that  the  secretion  of  the  lutein  cells 
of  the  corpus  luteum  of  each  period  prepared  the  uterus  for  the  menstruation 
of  the  next  period. 

This  destruction  of  the  fresh  corpus  luteum  was  carried  out  in  a  series  of 
nine  women,  who  were  being  operated  on  for  malposition  or  similar  troubles 
that  did  not  interfere  with  the  observations.  In  eight  of  the  nine  cases  the 
next  menstruation  was  missed,  the  succeeding  menstruations,  however,  occur- 
ring regularly. 

d.  In  that  class  of  cases  in  which  the  administration  of  desiccated  ovarian 
tissue  produces  beneficial  results  the  administration  of  lutein  tissue  alone  some- 
times gives  similar  results,  indicating  that  the  active  principle  of  ovarian 
tissue  is  contained  in  the  lutein  cells. 

THE  PAROVARIUM 

The  parovarium  is  the  remains  of  a  fetal  organ,  the  AVolffian  body,  which 
helps  to  form  the  generative  organs.  It  consists  of  a  triangular  group  of 
tubules  situated  in  that  part  of  the  broad  ligament  lying  between  the  ovary 
and  the  Fallopian  tube.  The  apex  of  the  triangle  lies  near  the  hilum  of  the 
ovary.  Beginning  near  the  hilum  of  the  ovary,  the  tubules  extend  upward, 
almost  parallel,  or  in  a  kind  of  fan-shaped  formation,  and  enter  a  transverse 
tube.  This  transverse  tube  is  called  the  ''head  tube"  and  it  terminates  in  a 
small  cul-de-sac  near  the  fimbriated  extremity  of  the  Fallopian  tube  (Figs. 
732,  733).  Very  often  this  little  cul-de-sac  becomes  distended  with  fluid  and 
forms  a  miniature  ejst  on  the  surface  of  the  broad  ligament.  But  the  little 
cyst  thus  formed  is  apparently  distinct  from  another  miniature  cyst  usually 
found  in  the  same  vicinity  and  called  the  ''hydatid  of  Morgagni."  The  hy- 
datid of  Morgagni  is  the  dilated  end  of  another  fetal  structure — the  duet  of 
Miiller,  which  forms  the  Fallopian  tube. 

Another  smaller  group  of  remnants  of  the  Wolffian  body  which  lies 
nearer  the  uterus  is  called  the  "paroophoron"  (Figs.  732,  733). 

The  tubules  of  the  parovarium  and  paroophoron  are  embedded  in  the 
delicate  connective  tissue  between  the  layers  of  the  broad  ligament  and  have 
no  connection  with  any  of  the  surrounding  organs. 

The  structure  has  no  function,  and  it  is  of  interest  chiefly  because  it 
gives  rise  to  certain  tumors  of  the  broad  ligament. 

CLASSIFICATION 

of  Tumors  of  the  Ovary 

It  will  be  noticed  that  in  the  following  table  are  included,  under  simple 
cysts  some  conditions  that  are  not  really  tumors  (new  growths),  but  only  in- 


CYSTIC    TUMORS    OF    THE    OVARY  923 

flammatory  and  iiutritial  changes.  Clinically,  however,  they  resemble  so 
closely  certain  new  growths  that  it  seems  best  to  consider  them  here.  Keep- 
ing in  mind  this  explanation,  and  also  the  fact  that  this  is  a  clinical  and  not 
a  pathologic  classification,  there  should  be  no  confusion. 

Ovarian  Tumors 

Cystic  Tumors  (95%). 
Simple  Cysts. 

Follicular  Cysts. 

Cysts  of  Corpus  Luteum. 

Tubo-ovarian  Cysts. 
Proliferating  Cysts  (Cystadenomata). 

Pseudomucinous  Cysts   (Cystadonoma  Evertens). 

Serous  Cysts  (Cystadenoma  Invertens). 
Dermoid  Cysts. 
Solid  Tumors  (5%). 

Fibromata. 

Fibromyomata. 

Papillomata  (of  surface). 

Carcinomata. 

Sarcomata. 

CYSTIC  TUMORS  OF  THE  OVARY 

These  comprise  simple  cysts,  proliferating  cysts  and  dermoid  cysts. 

DEFINITION  AND  PATHOLOGY 

Simple  Cysts 

Under  this  term  are  included  follicular  cyst,  corpus  luteum  cysts,  and 
tubo-ovarian  cysts. 

Follicular  Cysts  (Figs.  695,  734)  are  simply  unruptured  Graafian  follicles 
which  have  become  dilated.  The  increase  in  the  fluid  of  the  follicle  and  the 
consequent  formation  of  a  small  cyst  is  due  to  the  failure  of  the  follicle  to 
rupture.  This  failure  to  rupture  may  be  caused  by  the  deep  situation  of  the 
follicle  or  by  thickening  of  the  tunica  albuginea  (the  fibrous  coat  of  the 
ovary),  or  by  peritoneal  exudate  on  the  surface  of  the  ovary. 

These  follicular  cysts  are  small  and  rarely  produce  serious  symptoms. 
While  a  single  cyst  often  involves  only  a  part  of  the  ovarian  substance  (Fig. 
738),  in  other  instances  it  may  be  found  to  affect  the  entire  organ  (Fig.  739). 
They  are  frequently  found  in  chronic  oophoritis,  and  an  ovary  may  contain 
fifteen  or  twenty  of  them  and  still  not  be  more  than  twice  its  normal  size 
(Fig.  735).  Such  a  condition  is  designated  by  the  term  ''hydrops  folliculi" 
and  also  by  the  term  ''cystic  ovary."    Such  a  condition  is  not  an  indication 


924 


TUMORS   OF    THE   OVARY   AXD   PAROVAEIUM 


Fig.   734.     Follicular    Cysts   of   the    Ovary.      (Kelly — Operathe    Gynecology.) 


Fig.  735.     Cross  section   through   an   ovary  showing  two   rather  large   follicular   cysts. 


CYSTIC    TUMORS    OF    THE    OVARY 


925 


for  operation,  unless  there  are  serious  complications  or  unusually  severe 
symptoms.  Occasionally  a  follicular  cyst  "will  enlarge  to  the  size  of  the  fist 
(Fig.  396),  but  that  is  rare. 

It  was  formerly  supposed  that  the  large  proliferating  cysts  of  the  ovary 
were  derived  from  these  small  follicular  cysts,  but  that  theory  has  been 
abandoned. 

Corpus  Luteum  Cysts  (Fig.  736)  are,  as  their  name  indicates,  derived  from 
corpora  lutea,  which,  instead  of  undergoing  the  regular  process  of  absorption 
and  cicatrization,  undergo  a  cystic  change.  Microscopic  examination  of  the 
wall  of  such  a  cyst  will  show  the  lutein  cells,  characteristic  of  the  corpus 
luteum    (Fig.   737).      Corpus   luteum   cysts   are  usually   not   larger  than   an 


Fig.  736.     Corpus  Luteum  Cysts.     (Kelly — Operative-  Gynecology.) 

egg,  though  a  few  larger  ones  have  been  reported.  They  are  more  commonly 
seen  in  hydatidiform  moles. 

Tubo-ovarian  Cysts  are  those  cysts,  usually  small,  which  are  formed  by 
the  tube  and  the  ovary  combined  (Fig.  740).  A  simple  cyst  of  the  ovary  may 
rupture  into  an  adherent  tube,  or  a  dilated  tube  containing  fluid  (hydro- 
salpinx) may  become  adherent  to  an  ovary  and  rupture  into  it.  In  either 
case  the  wall  of  the  resulting  cavity  is  formed  by  both  the  tube  and  ovary; 
hence  the  name  "tubo-ovarian."     These  cysts  are  usually  small. 

None  of  the  conditions  described  under  simple  cysts  require  operation, 
unless  the  symptoms  are  very  troublesome  and  persistent.     If  the  condition 


926 


TUMORS   OF    THE   OVARY    AND   PAROVARIUM 


is  discovered  in  the  course  of  an  abdominal  section  for  some  other  trouble, 
the  pathologic  structure  should  ordinarily  be  resected,  with  the  sacrifice  of 
as  little  normal  tissue  as  possible. 


wm:WM'^ 


-^^.. 


Fig.  737.  L,ayer  of  Lutein  Cells,  which  is  the  distinguishing  element  in  the  wall  of  a  corpus  lutein 
cyst.  The  upper  part  of  the  drawing  indicates  the  appearance  of  the  corrugated  yellow  layer  in  the  cyst 
wall,  while  the  lower  portion  represents  a  high  magnification,   showing  the  individual   lutein   cells. 


Proliferating  Cysts 

These  are  the  ovarian  tumors  which  attain  such  a  large  size  (Fig.  741). 
This  is  the  form  of  growth  ordinarily  referred  to  when  an  "ovarian  cyst" 
or  "ovarian  tumor"  is  spoken  of. 

The  term  "proliferating"  is  given  to  these  growths  because  they  have 
the  faculty  of  generating  new  cysts  within  the  original  cyst  or  on  the  outside 
of  it.  They  increase  in  size  persistently  and  there  is  no  means  of  stopping 
their  growth,  except  removal. 

The  proliferating  cysts,  or  cystadenomata,  are  of  two  kinds- — the  pseudo- 
mucinous and  the  serous. 


CYSTIC    TUMORS    OF    THE    OVARY 


927 


Pseudomucinous  Cystadenomata.  These  are  known  also  as  ''paramuci- 
nous  cystadenomata"  and  as  "cystadenomata  evertens."  In  these  cysts  the 
contents  consist  of  a  jelly-like  material  which  is  secreted  by  the  epithelial 
cells  lining  the  cyst.  This  gelatinous  material  is  the  distinguishing  charac- 
teristic of  the  pseudomucinous  cyst  (Fig.  742).     On  chemical  examination  it 


Fig.  738.     Single  cyst  leaving  the  larger  portion  of  the  ovary  (left  upper  part  in  illustration)  intact. 


Fig.   739.      In   contrast   to   specimen   shown  in   Fig.    738;    in   this   case   the   cyst   formation   involves   the  entire 
ovary   which   had   to   be    removed   together   with   the   tube. 


shows  the  reaction  for  paramucin  or  pseudomucin  (not  precipitated  by  acetic 
acid,  but  precipitated  by  alcohol  as  delicate  threads,  which  are  insoluble  in 
water;  mucin  is  precipitated  by  acetic  acid,  and  albumen  is  precipitated  by 
heat).    The  color  of  this  gelatinous  material  depends  on  the  amount  of  blood- 


928 


TUMORS   OF    THE   OVARY    AND   PAROVARIUM 


coloring  v^^Mch  has  diffused  through  it  from  hemorrhage  into  the  cyst,  as 
explained  later. 

As  the  contents  are  formed  by  the  secretion  of  the  cells  lining  the  cyst, 
there  is  a  constant  increase  in  the  amount,  and  this  causes  constant  internal 
pressure,  which  keeps  the  wall  of  the  cyst  tense.  In  this  way  the  epithelial 
layer  is  kept  spread  out  (Fig.  744)  and  does  not  so  much  tend  to  pile  up  along 
the  wall  as  papillary  projections.     Rather  the  pressure  tends  to  depress  por- 


^■^■1 

HHHH 

^^^K^^^^K^^^^^^^^-mi^^l^^^Km 

^M 

^^ 

Fig.  740.     A  Tubo-ovarian   Cyst.     The   arrow,   passing  in   one  window  and   out   of  the   other,   indicates  the 
communication  between  the  ovarian  and  the  tubal  portion  of  the  cystic  mass. 


Fig.  741.     Patient  with  a  Large  Ovarian  Tumor. 


CYSTIC    TUMOES   OF    THE    OVARY 


929 


tions  of  the  wall,  and  as  the  epithelial  cells  multiply  they  are  pushed  further 
out  in  the  wall  in  the  form  of  gland-like  depressions  (Figs.  744  and  745); 
hence  the  name  "evertens."  The  depressions  may  become  occluded  at  the 
neck  and  are  thus  cut  off  from  the  main  cavity  forming  secondary  cysts 
(Fig.  743).  These  secondary  cysts  are  found  in  great  numbers  about  the 
primary  cyst  and  occasionally  one  or  more  of  the  secondary  cysts  may  become 
as  large  as  the  primary  one. 


Fig.  742.  A  Large  Pseudomucinous  Cystadenoma  of  the  Ovary.  In  this  case  the  contents  were  semi- 
solid like  jelly,  and  would  not  flow  through  the  largest  tube.  The  cyst  wall  was  so  friable  that  it  would  not 
stand  the  manipulations  necessary  to  scooping  out  the  cyst  contents,  so  it  was  necessary  to  remove  the  cyst 
like  a  solid  tumor  through  a  very  long  incision.  The  gelatinous  material  within  the  cyst  may  be  seen  pro- 
truding through  a  rent  in  the  wall  at  the  lower  part  and  also  at  the  upper  part. 


The  rule  that  pseudomucinous  cysts  are  evertent  is  not  absolute.  In 
nearly  all  such  cysts  there  are  a  few  insignificant  epithelial  ingrowths,  and 
in  rare  cases  these  growths  may  predominate,  giving  a  distinct  character' 
to  th.e  growth,  (pseudomucinous  cystadenoma  invertens).  Such  atypical  pseu- 
domucinous cysts  are  nearly  always  small,  indicating  that  there  was  not  much 
internal  pressure. 


930 


TU:\rORS    OF    the    ovary    AXD    PAROVARirM 


The  cells  lining  the  pseudomncinons  cyst  present,  on  microscopic  exami- 
nation, the  following  characteristics: 

They  contain  psendonmcin.  This  is  contained  in  the  inner  end  of  the 
cell  (the  end  next  to  the  cyst  cavity )— hence  this  end  of  each  cell  remains 
clear,  because  the  pseudomucin  does  not  take  the  ordinary  stain  nsed  in  the 
preparation  of  microscopic  specimens  (Figs.  745  and  746). 

There  are  goblet  cells  scattered  here  and  there  among  the  columnar  cells. 

The  cells  are  not  ciliated. 

The  pseudomucinous  cystadenomata  are  nearly  ahvays  confined  to  the 
ovary  of  one  side,  being  bilateral  only  very  rarely.     Such  a  cyst  may  start 


Fig.   743.     A   Pseudomucinous   Cj'Stadenoma   of   the   Ovary.      Notice   the    development    of   secondary   cysts   in 
the  wall  of  the  large  cyst.     (Kelly — Operative  Gynecology.) 

as  a  unicentral  growth  (giving  one  large  cyst) -or  as  a  multicentral  growth 
(giving  two  or  more  primary  cyst  cavities). 

Pseudomucinous  cysts  very  rarely  rupture  spontaneously.  ^ 

They  rarely  form  peritoneal  metastases.  The  apparent  peritoneal  me- 
tastases that  result  from  rupture  of  such  a  cyst  or  from  contamination  dur- 
ing removal  are  due  simply  "to  the  persistence  of  groups  of  cells  that  have 
lodged  on  the  peritoneum  and  secured  temporary  nourishment,  and  go  on 
for  a  time  producing  pseudomucin.  There  is  rarely  any  real  growth  or  mul- 
tiplication of  the  adherent  epithelial  cells.  They  usually  live  for  a  short 
time  only  and  then  disappear.  Occasionally,  however,  there  is  multiplication 
of  these  cells,  and  growth  all  through  the  abdominal  cavity,  giving  rise  to 


CYSTIC    TUMORS    OF    THE    OVARY 


931 


the  rare  condition  known  as  "pseudomyxoma  peritonei."  The  peritoneal 
cavity  becomes  filled  with  the  pseudomucinous  material,  which  is  reformed 
again  and  again  after  removal.  Most  of  these  patients  finally  succumb  to 
mechanical  interference  by  the  spreading  pseudomucinous  growth  or  to  the 
secondary  development  of  malignant  disease. 

Pseudomucinous  cysts  rarely  undergo  malignant  change,  except  as  above 
stated. 

The  cause  of  the  pseudomucinous  cyst  is  not  knoAvn  certainly.  They 
probably  start  from  the  primordial  follicles.  This  is  indicated  by  the  fact 
that  in  the  small  secondary  cysts,  in  the  w^all  of  the  main  cyst,  perfect  ova 


i^;.5i  :-y-j 


Fig.  744.  Photomicrograph  of  the  lining  of  a 
pseudomucinous  cyst,  under  low  power,  showing  the 
gland-like  depressions,  which  lead  to  the  formation 
of  secondary   cysts. 


Fig.  745.  Same  section,  under  higher  power. 
The  columnar  cells,  containing  pseudomucin,  do  not 
take   the  stain. 


have  been  found.  These  ova  were  formed  after  birth.  According  to  accepted 
theories,  the  only  cells  in  the  ovary  capable  of  forming  ova  after  birth  are 
tl%se  of  the  primordial  follicles.  All  the.  other  cells  have  been  differentiated 
past  this  stage. 

Serous  Cystadenomata.  These  are  known  also  as  ''papillary  cysts"  and 
as  ''cystadenomata  invertens."  The  contents  of  the  serous  cyst  partake 
of  the  nature  of  serum  and  do  not  present  the  gelatinous  character  of  that 
of  the  pseudomucinous  variety.  On  chemical  examination,  the  contents  show 
a  large  amount  of  albumen  and  no  pseudomucin.  The  contents  of  the  serous 
cysts,  like  those  of  the  other  variety,  may  vary  much  in  color  and  consistency — 
this  variation  being  due  to  the  amount  of  hemorrhage  into  the  cyst.     The 


932 


TUMORS   OF   THE   OVARY   AND   PAROVARIUM 


cells  apparently  have  no  secretion,  and  consequently  there  is  no  marked  intra- 
cystic  pressure  as  there  is  in  the  pseudomucinous  cyst.  On  account  of  this 
absence  of  internal  pressure  the  cells,  as  they  proliferate,  pile  up,  forming 
papillary  projections  into  the  interior  of  the  cyst  (Figs.  747,  748,  749,  750)  ; 
hence  the  name  ''invertens."  These  papillary  masses  (consisting  of  a  layer  of 
epithelial  cells  and  some  stroma),  Avhen  they  come  in  contact  with  the  opposite 


€§#'Mi^^ 


«»}       4    , 


^«?,ft\6\sWv 


Fig.  746. 


Indicating  the  difference  between  the  cells  lining  a  pseudomucinous  cyst    (A)    and  those  lining  a 
serous  cyst   (5),   as   explained   in  the   text. 


Fig.   747.     A   Papillary   Cystadenoma   of   the   Ovary.      The  papillary   projections   within  the   cyst   grow   to   the 
opposite  wall  and  then  penetrate  it.      (Pfannenstiel— f-V;"*'.?  Hand-Buck.) 

wall  of  the  cyst,  penetrate  the  wall  and  appear  outside  as  papillary  growths 
on  the  external  surface  of  the  cyst  (Fig,  749). 

Usually  a  few  gland-like  eversions  may  be  found  in  the  wall,  but  they 
are  insignificant.  Occasionally,  however,  a  serous  cystadenoma  will  present 
nearly  altogether  evertent  growths  (gland-like  projections  into  the  Avail  of 
the  cyst) — serous  cystadenoma  evertens. 


CYSTIC   TUMORS   OF   THE   OVARY 


933 


The  cells  lining  the   serous  cyst  present  the  following  characteristics: 
They  contain  no  pseudomncin,  hence  they  stain  throughout   (Fig.  746), 
There  are  no  goblet  cells — all  plain  columnar  cells. 
They  have  cilia. 


Fig.   748.     A   Papillary    Cystadenoma,    sectioned    and   showing   the   papillary   projections   into   the   cyst   cavity. 

(Penrose — Diseases   of    Women.) 


Fig.  749.  Papillary  Cystadenoma  of  each  Ovary.  On  the  left  side  the  internal  papillary  projections 
have  grown  through  the  opposite  wall  and  appear  on  the  external  surface.  On  the  right  side  the  papillary 
growths  have  obliterated  all  resemblance  to  a  cyst,  and  appear  simply  as  a  cauliflower  growth  in  the  region  of 
the  ovary.     Note  the  metastasis  on  the  peritoneal  surface  of  the  uterus.      (Penrose — Diseases  of  Women.) 

A  serous  cystadenoma  may  start  as  either  a  unicentral  or  a  multicentral 
growth.  It  does  not  form  such  a  large  tumor  as  the  pseudomucinous  cyst, 
and  it  is  nearly  always  unilocular,  except  when  it  begins  as  a  multicentral 


934  TUMORS   OF    THE   OVARY   AND   PAROVARIUM  . 

growth.  Serous  cysts  are  usually  bilateral  and  in  this  they  differ  markedly 
from  the  pseudomucinous  variety. 

A  striking  feature  of  these  serous  cysts  is  that  local  metastases  usually 
take  place.  When  such  a  cyst  ruptures,  extensive  local  metastases  form  on 
adjacent  peritoneal  surfaces,  producing  papillomatous  growths.  These 
growths  shoAV  no  malignant  structure,  but  they  may  kill  the  patient  by  ex- 
tensive local  growth,  though  they  do  not  penetrate  adjacent  organs  nor  cause 
distant  metastases.  They  may,  however,  and  in  fact  very  frequently  do,  un- 
dergo malignant  change,  in  which  case  they  become  ordinary  carcinomata. 

The  origin  of  the  serous  cysts  is  not  settled.  Some  authorities  hold  that 
they  arise  from  the  membrana  granulosa  of  the  Graafian  follicle.  It  is  held 
by  others  that  they  arise  from  parovarium  duct-remnants  in  the  ovary,  and 
there  are  some  facts  that  tend  to  support  this  theory.  In  structure  they  re- 
semble closely  certain  parovarian  cysts,  and  remnants  of  parovarian  ducts 
are  found  in  the  ovary  near  the  hilum,  which  is  just  the  part  of  the  ovary 
from  which  these  cysts  apparently  take  their  origin.  Moreover,  they  differ 
from  the  common  form  of  ovarian  papilloma,  which  originates  from  the 
surface  layer  of  epithelium  (the  germinal  epithelium),  though  the  term 
"ovarian  papilloma"  is  sometimes  applied  to  the  papillomatous  growth  re- 
sulting from  the  early  rupture  of  a  serous  cyst  and  in  which  the  cyst  charac- 
ter has  largely  disappeared. 

The  characteristics  of  the  pseudomucinous  and  serous  cysts  may  be  pre- 
sented and  contrasted  concisely  as  follows : 

Proliferating-  Cysts— Cystadenomata 
Pseudomucinous  Cyst  Serous  Cyst 

(Cystadenoma  Evertens)  (Cystadenoma  Invertens) 

1.  Contents  gelatinous  and  secreted  by  1.  Contents  serum-like  and  not  secret- 
the  cells  lining  the  cyst — may  be  'ed  by  the  cells  lining  the  cyst — 
any  color.  may  be  any  color. 

2.  Secondary  growths  consist  of  2.  Secondary  growths  consist  of  pap- 
gland-like  projections  outward  illary  projections  inward  (invert- 
(evertent)  from  the  cavity  into  the  ent)  from  the  wall  into  the  cavity, 
wall,  forming  small  cystic  cavities  forming  papillary  masses  which  ex- 
in  the  wall.  tend  across  the  cavity  and  pene- 
trate the  opposite  wall. 

3.  Lining  cells  contain  pseudomucin,  3.  Lining  cells  contain  no  pseudomu- 
are  columnar,  with  some  goblet  cin,  are  plain  columnar,  without 
cells,  and  are  not  ciliated.  goblet  cells,  and  are  ciliated. 

4.  Nearly  always  unilateral.  4.  Nearly  always  bilateral. 


CYSTIC    TUaiORS    OF    THE    OVARY 


935 


5.  Earely  ruptures  spontaneously. 


6.  Rarely  causes  peritoneal  metastases. 


5.  Usually  ruptures  at  an  early  stage, 
because  of  perforation  of  the  wall 
by  the  papillary  ingrowths. 

6.  Usually  causes  peritoneal  metasta- 
ses, consisting  of  widespread  papil- 
lary growths. 

7.  Rarely  undergoes  malignant  change,     7.  Frequently    undergoes    malignant 

change. 

8.  Rare. 

9.  Cause  unknown.  Probably  starts 
from  parovarian  tube-remnants  in 
the  ovary. 


8.  Very  common. 

9.  Cause    unknown.      Probably   start 

from  primordial  follicles. 


Taking  up  the  clinical  manifestations  of  the  proliferating  cysts  (both 
pseudomucinous  and  serous),  it  is  found  that  they  may  occur  at  any  age, 
but  are  most  frequent  during  the  period  of  greatest  ovarian  activity,  i.e., 
between  the  twentieth  and  fiftieth  years.    Either  ovary  may  be  affected.   They 


Fig.   750.     A   case    of   bilateral   proliferating   papillary    ovarian   cystoma.      The   papillary    growth    is    distinctly 

visible   on   the   larger  tumor   to   the   left. 


are  bilateral  in  only  about  3  per  cent  of  the  cases,  while  malignant  tumors  of 
the  ovary  are  bilateral  in  about  75  per  cent  of  the  cases.  As  mentioned  be- 
fore, the  serous  or  papillary  proliferating  cysts  are  usually  bilateral,  but  they 
constitute  only  a  small  proportion  of  proliferating  cysts — most  of  such  cysts 
being  of  the  pseudomucinous  variety. 

In  shape,  a  pi-oliferating  cyst  may  be  spherical  and  regular  in  outline, 
indicating  a  single  large  cyst,  or  it  may  be  irregular,  presenting  nodules  in- 


936 


TUMORS   OF    THE   OVARY   AND   PAROVARIUM 


dicating  a  multilocular  cyst.  In  size  these  cysts  vary  from  a  small  tumor  the 
size  of  an  egg  to  a  large  tumor  fiUmg  the  whole  abdomen. 

As  to  appearance  when  exposed  by  abdominal  incisions,  the  wall  of  the 
cyst  presents  a  Avhite,  glistening  appearance.  The  thinner  portions  are  straw- 
colored  or  green  or  black,  according  to  their  fluid  contents.  The  surface  of 
the  cyst  may  be  perfectly  smooth,  or  may  be  covered  by  a  papillary  growth, 
or  may  be  bound  to  adjacent  structures  by  adhesions.  The  tumor  usually  has 
a  distinct  pedicle. 

The  cysts  are  divided  into  three  classes  according  to  their  internal  struc- 
ture— unilocular,  multilocular  and  areolar.  Unilocular  cysts  may  be  very 
large,  but  they  are  found  to  consist  of  only  one  large  cyst.    However,  the  in- 


Fig.   751.     Portion   of  the   Wall  of  a  Dermoid   Cyst   of  the   Ovary,      a.   Wall   of   cyst.      b.   Mass   of  cutaneous 
tissue,     c.  Hair.     d.  Teeth.      (Thomas  and  Munde,  after  Ziegler — Diseases  of   Women.) 


terior  frequently  shows  remains  of  trabeculae,  indicating  that  they  were  at 
one  time  multilocular  cysts.  Multilocular  cysts  contain  two  or  more  cysts  of 
medium  size,  besides  a  large  number  of  smaller  cavities  (Fig,  743).  Areolar 
cysts  are  made  up  of  a  large  number  of  small  cavities  of  various  sizes  and 
shapes. 

The  cyst  wall  consists  of  three  layers — an  outer  and  inner  firm  fibrous 
layer,  with  xi  middle  layer  of  looser  tissue  betAveen  them.  In  the  middle  layer 
of  loose  connective  tissue  the  vascular  supply  is  distributed.  Those  vessels 
Avhich  come  near  the  outer  surface  may  often  be  plainly  seen,  and  they  are 
frequently  very  large.     The  external  surface  of  the  cyst-wall  is  covered  with 


CYSTIC    TUMORS    OF    THE    OVARY 


937 


Fig.  752.  A  small  Dermoid  Cyst,  showing  teeth,  hair,  sebaceous  material  and  firm  fat-tissue.  The 
teeth,  shown  in  the  right  side,  are  unusually  well  developed  and  constitute  a  point  of  special  interest  in  this 
specimen.     (Specimen  of  Dr.  F.  J.  Taussig.) 


Fig.   753.     Hair,   five  and  a  half  feet  long,   from  Fig.   754.     Balls    of    Sebaceous    Material    from    a 

a  Dermoid  Cyst.     (Thomas  and  Munde — Diseases  of        Dermoid    Cyst.      (Thomas    and    Munde — Diseases   of 
Women.)  Women.) 


938 


TUMORS    OF    THE    OVARY    AND    PAROVARIUM 


columnar  epithelium,  derived  from  the  germinal  epithelium  covering  the  sur- 
face of  the  ovaiy  and  differing  from  the  endothelium  of  the  peritoneum.  The 
internal  surface  is  lined  ^vith  low  columnar  cells.  The  lining  membrane  is 
often  covered  vrith  ^'egetations  and  irregular  gro^i:hs,  both  cystic  and  solid. 

The  contents  of  cysts  present  marked  contrast  in  consistency  and  in  color. 
The  contents  may  be  thin  like  water  (serous  cysts),  or  thick  and  viscid  and  of 
gelatinous  consistency  (pseudomucinous  cyst).  The  contents  may  be  almost 
colorless  or  strav-colored  or  a  dirty  yellow,  or  green  or  black.  The  color  de- 
pends on  hemorrhage  into  the  cyst.  The  coloring  matter  of  the  blood  be- 
comes the  coloring  matter  of  the  cyst  contents. 

As  these  cysts  enlarge  they  bear  various  relations  to  adjacent  structures. 
Tf  they  rise  out  of  the  pehis  and  enlarge  in  the  abdomen,  they  may  attain  a 


Fig.   755.      Section   through   an   ovarian    dermoid.      Imbedded   into    the    mass    of   sebaceous   material    are   seen 

balls  of  hair. 


very  large  size  before  producing  serious  symptoms.  They  there  have  plenty 
of  room  and  expand  freely,  pushing  aside  the  surrounding  organs.  If  they  be- 
come caught  under  the  pelvic  brim  and  develop  in  the  pelvis,  they  soon  begin 
to  cause  pain  and  other  disturbances  from  pressure  and  distortion  of  the 
organs. 

The  proliferating  papillary  cysts,  or  serous  cysts,  before  described,  itsu- 
ally  rupture  rather  early  and  fill  the  pelvis  Avith  papillary  growths.  In  such 
a  case  the  first  impression,  Avhen  the  abdomen  is  opened,  is  that  the  pelvis  is 
filled  with  a  cancerous  mass,  Avhich  can  not  be  removed  and  which  will  soon 
cause  death.  Accordingly,  in  not  a  few  cases,  the  operator,  after  scraping  out 
some  of  the  papillary  bleeding  growth,  has  closed  the  abdomen  and  told  the 


CYSTIC    TUMORS    OF    THE    OVARY  939 

patient  or  her  friends  that  there  was  an  inoperable  cancer  and  that  she  could 
not  long  survive.  Some  such  patients  get  entirely  well  after  the  operation. 
In  other  cases  malignant  change  has  already  begnn  or  begins  later  and  the 
patient  dies  of  carcinoma.  In  still  other  cases  the  growth  itself  becomes  so 
extensive  as  to  interfere  with  the  functions  of  adjacent  organs  and  thus  causes 
death. 

Dennoid  Cysts  of  the  Ovary 

Dermoid  cysts  are  those  in  which  are  found  skin  or  mucous  membrane, 
associated  with  structures  generally  connected  with  the  epidermal  tissues. 
The  structures  most  frequently  found  are  hair,  teeth,  bone,  muscle-fibers,  skin 
and  small  balls  of  sebaceous  material  resembling  fat  (Figs.  751,  752,  753,  754 
and  755). 

Dermoid  tumors  may  appear  at  any  age.  They  have  been  found  in  chil- 
dren at  birth  and  in  women  of  ninety  years. 

Dermoid  tumors  of  the  ovary  are  comparatively  small,  rarely  getting 
larger  than  a  child's  head.  But  they  are  more  dangerous  than  the  ordinary 
large  cysts,  for  the  dermoid  cysts  usually  present  more  and  firmer  adhesions, 
and  their  contents  are  more  irritating,  so  much  so  that  the  escape  of  any  of 
the  contents  into  the  peritoneal  cavity  is  likely  to  cause  a  fatal  peritonitis. 
They  are  much  more  liable  to  suppuration  and  consequent  abscess  formation 
than  the  ordinary  cysts. 

SYMPTOMS  AND  DIAGNOSIS 

of  Ovarian  Cysts 

As  the  simple  cysts  seldom  give  rise  to  serious  trouble  and  the  dermoid 
cysts  are  rare,  the  symptoms  to  be  mentioned  belong  to  the  proliferating 
cysts  and  principally  to  the  pseudomucinous  variety,  as  the  vast  majority  of 
cystic  ovarian  tumors  belong  to  this  class. 

An  ovarian  cyst  usually  develops  slowly  and  may  attain  considerable  size 
before  it  is  discovered.    Often  it  is  noticed  then  only  by  accident. 

The  earliest  symptoms  are  a  feeling  of  weight  and  pressure  in  the  pelvis, 
bladder  irritability,  slight  menstrual  disturbance,  constipation  and  perhaps 
some  pain  with  bowel  movement.  The  symptoms  are  not  distinctive,  but  sim- 
ply indicate  some  disturbing  factor  in  the  pelvis.  As  the  tumor  increases  in 
size,  distinct  pressure-symptoms  appear  and  the  general  nutrition  becomes 
affected.  There  is  enlargement  of  the  abdomen,  swelling  of  the  feet  from 
pressure  on  veins,  pain  from  pressure  on  nerves  and  dyspnea  from  pressure 
on  the  diaphragm.  There  appear,  also,  stomach  disturbances,  emaciation  and 
progressive  weakness.  In  some  cases  there  are  attacks  of  local  peritonitis, 
with  severe  abdominal  pain  and  some  fever,  but  these  inflammatory  symp- 


940 


TUMORS   OF    THE   OVARY   AND   PAROVARroM 


toms  are  due  to  complications  and  do  not  belong  to  the  natural  history  of  the 
tumor. 

Ovarian  cysts  grow  sloAvly,  usually  taking  several  years  to  reach  a  large 
size.  But  they  seldom  stop  growing.  They  persistently  enlarge  until  the  pa- 
tient finally  dies  from  exhaustion  brought  about  by  pressure-effects  on  vital 
organs. 

The  diagnosis  in  typical  cases  is  easy,  but  in  complicated  cases  it  may  be 
very  difficult,  and  in  exceptional  cases  a  positive  exact  diagnosis  is  impossible 
before  operation.    Tapping  the  cyst  through  the  abdominal  wall  as  an  explora- 


Fig.   756.     Microscopic  section  from  the  wall  of  a  dermoid  cyst,  showing  the  thick  layer  of  stratified  squamous 

epithelium  and  sebaceous  gland. 

five  measure  should  not  be  employed.  An  adherent  coil  of  intestine  may  be 
punctured,  or  cyst  contents  may  leak  into  the  peritoneal  cavity  and  cause 
fatal  peritonitis.  In  a  doubtful  case,  an  exploratory  abdominal  section  is  safer 
and  far  more  satisfactory  in  diagnostic  results. 

In  taking  up  the  differential  diagnosis  of  ovarian  cysts,  it  is  at  once  ap- 
parent that  the  symptoms  and  diagnostic  points  are  different  in  the  different- 
sized  tumors. 

Small  Ovarian  Cyst 

Considering  the  small  ovarian  cyst  according  to  the  "Points  in  the  Dif- 
ferential Diagnosis  of  Various  IMasses  in  the  Pelvis  and  Lower  Abdomen'' 
(Diagnostic  Table,  page  327),  it  is  found  that  an  ovarian  cyst  of  this  size  pre- 
sents the  following  characteristics  (the  numbers  refer  to  the  "Points"  in  tJie 
Diagnostic  Table). 

1.  Is  situated  in  the  lateral  part  of  the  pelvis,  though  in  exceptional  cases 
it  may  drop  down  directly  iDehind  the  uterus  or  in  front  of  it. 


CYSTIC    TUMORS    OF    THE    OVARY  941 

2.  Tlie  small  ovarian  cyst  is  the  size  now  under  consideration — about  as 
large  as  the  fist  or  a  little  larger. 

3.  Is  approximately  spherical,  though  may  be  made  uneven  by  secondary 
cysts. 

4.  Contains  fluid   (fluctuates). 

5.  Is  not  tender,  unless  complicated  by  inflammation  or  by  torsion  of 
pedicle. 

6.  Is  freely  movable,  unless  complicated  by  adhesions  or  caught  under 
the  sacral  promontory. 

7.  Is  attached  in  the  lateral  part  of  the  pelvis. 

8.  Apparently  arises  from  the  tubo-ovarian  region. 

9.  Lies  beside  the  uterus,  but  is  not  attached  to  it  and  does  not  ordinarily 
modify  it  in  any  way,  except  to  cause  some  displacement  towards  the  opposite 
side. 

18.  Occupies  the  tubo-ovarian  region. 

36.  Symptoms  slight,  unless  complicated.  No  history  of  fever  or  of  at- 
tacks of  pelvic  inflammation. 

50.  Progressive  increase  in  size,  without  inflammatory  symptoms. 

57.  Fallopian  tube  lies  close  to  the  mass,  but  can  in  some  cases  be  distin- 
guished from  it.  The  ovary  is  not  found  because  incorporated  in  the  mass. 
The  uterus  is  of  normal  size,  though  it  may  be  somewhat  displaced.  The  mass 
is  freely  movable,  unless  complicated,  and  can  be  separated  from  the  uterus 
and  from  the  pelvic  wall  and  from  the  Fallopian  tube  and  from  most  of  the 
bread  ligament,  but  not  from  the  ovary. 

The  following  conditions  may  be  confounded  with  a  small  ovarian  cyst 
and  must  therefore  be  taken  into  consideration  in  the  differential  diagnosis: 

a.  Inflammatory  Mass   (salpingitis  with  exudate,  pyosalpinx,  hydro- 

salpinx) . 

b.  Tubal  Pregnancy. 

c.  Fibroid  Tumor  of  the  Uterus. 

d.  Retroverted  Pregnant  Uterus. 

e.  Broad  Ligament  Cyst. 

a.  Inflammatory  Mass.  There  are  three  kinds  of  masses  resulting  from  in- 
flammation or  allied  conditions  that  must  be  taken  into  consideration. 

Salpingitis  with  Exudate  presents  a  mass  which  is  (1)  situated  in  the  tubo- 
ovarian  region,  (2)  irregular  in  shape,  (3)  firm,  (4)  very  tender,  (5)  fixed 
by  adhesion,  (6)  attached  to  both  the  pelvic  wall  and  the  uterus,  (7)  appar- 
ently originates  in  adnexal  region,  (8)  attached  to  upper  lateral  part  of 
uterus,  but  a  sulcus  can  be  made  out  between  the  uterus  and  the  mass,  (15) 
uterus  fixed,  but  not  otherwise  modifi.ed  except  perhaps  somewhat  displaced 
to  the  opposite  side,  and  (16)  there  is  discharge  from  the  uterus  due  to 
the  preceding  endometritis.  The  tube  and  ovary  are  (18)  included  in  the 
mass,  (19)  the  mass  is  adherent  to  the  pelvic  wall,  (23)  there  may  be  a  mass 


942  TUMORS    OF    THE    OVARY    AXD    PAROVARIUM 

about  the  opposite  tube,  (32;  there  is  fever  if  the  trouble  is  acute,  there  is  a 
history  of  (36)  sudden  onset,  T^ith  pain  in  the  lower  abdomen  and  fever,  and 
confinement  to  bed  following  labor  or  miscarriage  or  instrumentation,  or  gonor- 
rhea or  chronic  endometritis,  (37)  remissions  and  exacerbations  with  pelvic 
pain  and  disability,  (38)  menstrual  disturbance  (usually  painful  menstrua- 
tion), (40)  leucorrhea,  (41)  backache  practically  all  the  time  and  aching  in 
pelvis,  with  sharp  pain  in  pelvis  during  the  exacerbations,  (42)  fever  more  or 
less  during  the  exacerbations,  (43)  some  disability  all  the  time  and  usually 
confined  to  bed  for  a  few  days  or  longer  during  the  exacerbations.  Any  in- 
crease in  size  (50)  is  accompanied  by  inflammatory  symptoms.  If  the  patient 
is  examined  under  anesthesia,  it  is  found  that  (51)  the  mass  occupies  the 
region  of  the  tube  and,  usually,  includes  the  ovary  also,  (53)  is  firm  through- 
out, (54)  is  fixed  by  adhesions,  (55)  is  attached  to  surrounding  organs,  (56) 
originates  from  the  tube  or  ovary,  (57)  the  mass  can  be  differentiated  from  the 
uterus,  but  not  from  the  tube  and  usually  not  from  the  ovarj-,  and  (58)  the 
uterus  is  normal  except  for  the  leucorrheal  discharge  and  the  fixation,  and 
perhaps  some  displacement  towards  the  opposite  side. 

Pyosalpinx  presents  practically  the  same  symptoms  and  signs,  except  that 
the  one  or  more  points  of  fluctuation  are  present  and  the  tenderness  is  more 
marked,  and  the  inflammatory  symptoms  and  exacerbations  are  more  severe. 

In  Hydrosalpinx  the  inflammatory  symptoms  have  practically  disappeared, 
leaving  the  distended  fluctuating  tube  with  some  adhesions.  It  differs  from 
the  ovarian  cyst  in  that  (3)  the  mass  in  typical  cases  is  elongated  and  "sau- 
sage-shaped," (6)  is  less  movable  than  the  ovarian  tumor,  (7)  is  attached  to 
the  pelvic  wall  and  to  the  uterus,  though  in  some  cases  the  attachment  is  not 
very  close,  (8)  appears  to  arise  from  all  along  the  upper  margin  of  the  broad 
ligament,  (18)  the  tube  is  included  in  the  mass,  while  the  ovary  can  in  some 
eases  be  differentiated,  (36)  there  is  a  history  of  previous  pelvic  inflammation, 
(38)  menstrual  disturbance  and  other  evidence  of  previous  inflammation  in 
the  uterus,  and  (57)  if  patient  is  examined  under  anesthesia,  it  may  usually  be 
determined  definitely  that  the  tube  is  involved  in  the  mass  and  that  the  ovary 
is  separate. 

b.  Tubal  Pregnancy  presents  the  pain,  disability,  tenderness  and  fixation 
of  an  inflammatory  mass,  with  little  or  no  fever,  but  with  the  addition  of  the 
special  evidences  of  extrauterine  pregnancy  given  in  the  previous  chapter 
(page  882). 

c.  Fibroid  Tumor  of  uterus  presents  a  mass  which  differs  from  an  ovarian 
cyst  in  that  it  is  (1)  situated  near  the  center  of  the  pelvis,  (3)  irregular  in 
shape,  (4)  firm  throughout,  or  if  it  is  a  cystic  fibroid  the  larger  part  of  the 
mass  is  firm,  (6)  not  movable  separately  from  the  uterus,  but  the  mass  and 
the  uterus  are  movable  in  the  pelvis,  (7)  attached  to  the  uterus,  (8)  appar- 
ently arises  from  the  uterus,  and  (9)  is  so  intimately  associated  with  the 
uterus  that  it  seems  to  be  part  of  the  organ.  The  uterus  is  usually  (10)  dis- 
placed someAvhat  by  the  mass,  (11)  increased  in  size,  (12)  irregular  in  shape 


CYSTIC    TUMORS    OF    THE    OVARY  943 

and  (16)  presents  some  discharge  from  the  accompanying  endometrial  dis- 
turbance. There  are  (23)  likely  to  be  other  masses  projecting  from  the  uterus 
and  there  is  a  history  of  (38)  menstrual  disturl^anee  (usually  excessive  men- 
struation), (40)  leucoi-rhea,  (41)  pressure  and  aching  in  the  pelvis  and  (57) 
if  the  patient  be  examined  under  anesthesia,  it  is  found  that  the  mass  is  in- 
timately associated  with  the  uterus  and  that  the  tubes  and  ovaries  are  separate, 
unless  the  mass  is  so  large  as  to  obscure  these  structures. 

d.  Retroverted  Pregnant  Uterus.  This  would  cause  confusion  in  diagnosis 
only  when  incarcerated  in  the  pelvis  so  that  it  could  not  be  raised  sufficiently 
to  be  brought  forward  nor  satisfactorily  outlined.  It  would  then  differ  from 
an  ovarian  cyst  in  that  the  mass  is  (1)  situated  in  the  median  line,  (4)  partly 
solid,  (5)  tender,  (6)  not  movable,  (7)  filling  posterior  part  of  pelvis,  (8) 
seems  to  be  a  continuation  of  the  cervix  uteri  and  (9)  apparently  the  ex- 
panded uterus  containing  fluid.  There  is  softening  (13)  of  the  cervix  and 
corpus  uteri  and  (17)  venous  discoloration  of  the  cervix  and  vagina.  There  is 
a  history  of  (38)  amenorrhea,  (46)  morning  sickness  and  (47)  pains  and 
tenderness  in  the  breasts.  If  the  patient  is  examined  under  anesthesia  (57), 
the  mass  is  identified  with  the  uterus  (enlarged,  softened,  retroverted  and 
containing  fluid),  and  the  tubes  and  ovaries  are  distinguished  as  separate  un- 
less the  mass  is  so  large  that  it  obscures  them. 

e.  Broad  Ligament  Cyst.  This  differs  from  the  ovarian  cyst  in  that  it  is 
(1)  situated  deeper  in  the  pelvis,  (6)  not  so  movable,  (7)  attached  to  pelvic 
wall  and  uterus,  (8)  originates  in  the  lateral  pelvic  region,  (9)  extends  down 
the  side  of  the  uterus  to^A-ard  the  cervix,  (10)  displaces  the  uterus  markedly 
toAvard  the  opposite  side  and  (15)  fixes  the  uterus  to  some  extent.  If  the  pa- 
tient be  examined  under  anesthesia,  it  is  found  (57)  that  the  mass  is  located 
in  the  broad  ligament  below  the  tube,  and  the  tube  and  ovary  can  be  dis- 
tinguished as  separate  unless  obscured  by  the  mass. 

Large  Ovarian  Cyst 

A  growth  large  enough  to  cause  the  abdomen  to  be  prominent  must  be 
differentiated  from  the  following  conditions : 

a.  Tympanites  and  "Phantom  Tumor." 

b.  Obesity. 

c.  General  Ascites. 

d.  Pregnancy   (normal,  with  hydramnios,  extrauterine). 

e.  Cystic  Fibroid  of  Uterus. 

f.  Distended  Bladder. 

g.  Tumor  of  some  Abdominal  Organ, 
h.  Tubercular  Peritonitis. 

a.  Tympanites  presents  resonance  over  all  the  abdomen.  The  vagino-ab- 
dominal  examination  shows  that  there  is  no  abnormal  mass  in  the  pelvis  or 


944  TUMORS   OF    THE   OVARY   AND   PAROVAEroM 

lower  abdomen  (Fig.  139).  ''Phantom  tumor"  is  a  term  applied  to  certain 
conditions  produced  by  irregular  contraction  of  the  abdominal  muscles  (forc- 
ing tympanitic  intestines  into  some  locality  in  such  a  way  as  to  give  the  ap- 
pearance of  a  tumor),  accompanied  with  marked  hyperesthesia.  It  occurs  usu- 
ally in  hysteric  subjects  and  the  apparent  tenderness  may  be  so  marked  as  to 
prevent  satisfactory  palpation,  either  abdominal  or  bimanual.  Usually  it  can 
be  made  out  that  there  is  distinct  resonance  over  the  swelling  and  that  there 
is  no  abnormal  mass  in  the  pelvis.  When  in  doubt,  examine  the  patient  under 
anesthesia,  when  the  muscular  tension  and  the  consequent  "tumor"  will  dis- 
appear. 

b.  Obesity  may  produce  marked  prominence  of  the  abdomen  and  has  been 
mistaken  for  ovarian  cyst  (Fig.  129).  Resonance  may  be  obtained  in  deep 
percussion  over  all  the  abdomen,  showing  that  there  is  no  mass  between  the 
intestines  and  the  abdominal  wall.  Also,  in  picking  up  the  wall  to  test  its 
thickness  (Figs.  126,  127)  it  is  found  that  most  of  the  prominence  is  due  to 
the  thickness  of  the  wall.  On  vagino-abdominal  examination  no  abnormal 
mass  is  felt  in  the  pelvis  or  lower  abdomen. 

c.  General  ascites  presents  ordinarily,  when  the  patient  is  lying  on  her 
back,  resonance  at  the  top  of  the  abdomen  and  dullness  in  the  flanks  (Figs. 
171,  172).  When  the  patient  changes  posture  the  outline  of  dullness  changes, 
as  the  free  fluid  goes  to  the  lowest  part  of  the  peritoneal  cavity  (Fig.  174). 
There  is  a  percussion  wave  in  ascites  (Figs.  33,  34).  Yagino-abdominal  ex- 
amination shows  that  there  is  no  mass  in  the  pelvis  or  lower  abdomen.  The 
presence  of  disease  of  the  heart  or  liver  or  kidneys  sufficient  to  account  for 
the  ascites  is  a  point  in  favor  of  the  same. 

d.  Pregnancy.  Normal  pregnancy  presents  missed  menses,  morning  sick- 
ness, enlarged  breasts,  vaginal  and  cervical  discoloration  and  softening  of  the 
cervix.  The  examiner  can  usually  distinguish  the  fetal  parts  and  may  be  able 
to  feel  fetal  movements  or  hear  the  fetal  heart  sounds.  In  pregnancy  with 
hydramnios  the  symptoms  and  signs  are  about  the  same  as  in  normal  preg- 
nancy, except  that  there  is  more  fluid,  and  consequently  it  is  the  more  dif- 
ficult to  feel  the  fetus  or  to  get  the  fetal  heart  sounds.  In  extrauterine  preg- 
nancy there  are  the  usual  symptoms  of  pregnancy,  with  the  addition  of  certain 
anomalous  symptoms,  indicating  that  the  pregnancy  is  in  the  peritoneal  cavity 
instead  of  within  the  uterus.  Also,  in  the  early  history  of  the  trouble  there  are 
indications  of  pelvic  inflammation,  with  the  added  special  characteristics  of 
tubal  pregnancy  enumerated  in  the  preceding  chapter  (page  883). 

e.  Cystic  Fibroid.  This  presents  an  irregular  mass  situated  in  the  central 
part  of  the  pelvis,  and  apparently  it  arises  from  or  is  a  part  of  the  uterus,  from 
which  it  can  not  be  separated.  A  large  part  of  the  mass  is  firm.  It  dis- 
torts the  uterus  and  increases  the  length  of  the  cavity.  There  is  usually  a 
history  of  excessive  menstruation  and  of  leucorrheal  discharge. 

f.  Distended  Bladder.  It  has  happened  that  a  distended  bladder  went  un- 
recognized until  rupture  of  the  bladder  and  death  of  the  patient.     In  a  case 


CYSTIC    TUMORS   OF    THE    OVARY  945 

of  distended  bladder  the  history  shows  first  difficulty  in  passing  urine  and 
later  constant  dribbling  of  urine  due  to  the  overdistention.  There  may  be 
symptoms  of  uremia.  When  the  patient  is  catheterized  the  supposed  tumor  dis- 
appears, but  it  may  require  a  very  long  catheter  to  reach  the  urine  because  of 
the  distortion  and  lengthening  of  the  urethra. 

g.  Tumor  of  Some  Abdominal  Organ.  This  presents  the  fixed  or  least 
movable  portion  at  some  organ  in  the  abdomen,  the  rounded  free  border  ex- 
tending toward  the  pelvis  or  into  the  pelvis.  The  mass  may  be  displaced  up- 
ward into  the  abdominal  cavity  and  then  the  pelvis  is  clear.  There  are  symp- 
toms associated  with  the  organ  involved,  and  no  particular  symptoms  of  dis- 
turbance of  the  pelvic  organs. 

h.  Tubercular  Peritonitis.  There  is  fluid  in  the  abdominal  cavity,  either 
free  or  encysted,  associated  with  evidences  of  tubercular  inflammation  in  the 
pelvis  (page  872)  or  in  the  abdominal  cavity  or  in  both.  There  are  frequently 
evident  signs  of  tuberculosis  elsewhere,  usually  in  the  lungs  or  in  the  intes- 
tines. The  tuberculin  reactions  may  aid  materially  in  determining  whether  the 
intraabdominal  trouble  is  tubercular. 


COMPLICATIONS 

Having  determined  that  an  ovarian  cyst  is  present,  we  must  then  consider 
certain  complications  that  may  be  present  or  that  may  appear  later.  These 
complications  are  as  follows : 

1.  Local  i)eritonitis,  forming  adhesions. 

2.  Hemorrhage  into  the  cyst. 

3.  Rotation  of  the  cyst,  producing  torsion  of  the  pedicle. 

4.  Inflammation  and  suppuration  of  the  cyst. 

5.  Rupture  of  the  cyst. 

6.  Ascites  accompanying  the  tumor. 

7.  Intestinal  obstruction. 

1.  Local  Peritonitis  is  accompanied  with  some  pain  and  tenderness  over 
a  part  of  the  tumor.  There  may  be  some  fever,  but  usually  this  symptom  is 
not  marked;  the  process  consists  simply  of  irritation  at  some  portion  of  the 
outer  surface  of  the  cyst  and  the  formation  there  of  i)lastie  exudate,  binding 
the  cyst  to  some  adjacent  organ  or  to  the  abdominal  Avail.  In  a  few  days  the 
pains  disappear,  but  the  exudate  remains,  becomes  organized  and  forms  an 
adhesion,  which  may  interfere  more  or  less  with  the  subsequent  operation. 

2.  Hemorrhage  into  the  Cyst  is  what  gives  the  various  colors  to  the  cyst 
contents.  This  hemorrhage  usually  takes  place  slowly  in  small  quantities  and 
without  clinical  symptoms.  Occasionally,  however,  a  copious  hemorrhage 
takes  place,  usually  from  some  interference  with  the  venous  return,  such  as 
twisting  of  the  pedicle  or  pressure  of  an  enlarged  uterus,  or  it  may  follow  tap- 


946 


TUMORS   OF    THE   OVARY    AND   PAROVARIUM 


ping  of  the  cyst.     The  hemorrhage  may  be  so  severe  as  to  cause  collapse  oi 

the  patient. 

3.  Rotation  of  the  Cyst  may  take  place  where  the  pedicle  is  long  (Figs. 
403,  757).     The  amount  of  rotation  varies  from  a  half  turn  to  several  corn- 


Fig.  757.  Rotation  of  an  Ovarian  Cyst.  The  turning  of  the  tumor  twists  the  pedicle,  blocking  the 
circulation  and  causing  thrombosis  in  the  pedicle  and  throughout  the  tumor.  The  extravasation  of  blood 
causes  the  affected  tissues  to  become  black. 


plete  turns.  Torsion  of  the  pedicle  is  supposed  to  be  favored  by  an  injury, 
such  as  a  fall  or  blow,  and  by  active  exercise,  and  also  by  the  alternate  filling 
and  emptying  of  the  bladder  and  the  bowel,  and  during  pregnancy  by  the  en- 
largement of  the  uterus. 


CYSTIC    TUMORS    OF    THE    OVARY  947 

The  effect  of  torsion  of  the  pedicle  on  the  circulation  of  the  tumor  depends, 
of  course  on  the  amount  of  rotation.  The  veins  are  the  first  to  suffer.  The 
iii)w  of  blood  in  them  is  impeded,  causing  the  tumor  to  become  engorged,  and 
ih^re  is  hemorrhage  into  the  interior  of  the  cyst,  either  in  the  form  of  extrav- 
asation or  the  rupture  of  a  vein  with  severe  hemorrhage.  If  the  twisting  in- 
creases, there  is  thrombosis  of  the  vessels  and  extravasation  of  bloody  fluid 
into  the  peritoneal  eavitj^,  and  later  necrosis  of  the  tumor,  followed  by  fatal 
peritonitis.  The  hemorrhage  into  the  tumor  causes  it  to  appear  black  (Fig. 
741).  The  symptoms  of  torsion  of  the  pedicle  are  very  marked.  When  a  pa- 
tient with  an  ovarian  tumor  complains  of  sudden'  pain  in  the  abdomen  and  has 
vomiting,  and  there  is  a  sudden  increase  in  the  size  of  the  tumor,  it  is  prob- 
able that  torsion  of  the  pedicle  has  taken  place.  In  some  cases  there  are  re- 
peated attacks  of  slight  torsion. 

4.  Inflammation  and  Suppuration  of  the  Cyst.  This  is,  of  course,  due  to 
infection.  The  infection  may  come  from  the  intestinal  canal  or  from  the  blad- 
der or  from  a  Fallopian  tube  or  from  tapping  the  cyst.     The  most  common 


Fig.   7SS.     A  Small   Ovarian  Fibroma.      Cross  section,  showing  the  typical  fibromatous  structure   and  a  well- 
defined  capsule. 

source  of  infection  is  the  Fallopian  tube.  The  patient  contracts  salpingitis, 
adhesions  form  between  the  inflamed  tube  and  the  cyst  wall,  and  infection 
spreads  along  these  adhesions  and  invades  the  cyst.  Adhesions  with  some 
portions  of  the  intestinal  tract,  especially  with  the  appendix,  may  likewise 
lead  to  infection  of  the  cyst.  Tapping,  which  was  formerly  common,  often 
led  to  infection  of  the  cyst.  Dermoid  cysts  are  especially  prone  to  suppuration. 
Infections  of  cysts  are  not  uncommonly  seen  in  the  course  of  the  acute  infec- 
tious fevers,  especially  typhoid. 

The  symptoms  of  suppuration  of  the  cyst  are  pain,  fever,  tenderness  over 
the  tumor,  rapid  pulse  and  exhaustion  and  emaciation.  If  the  suppurating 
cyst  does  not  speedily  cause  death  bj^  peritonitis,  it  may  later  rupture  into 
the  intestine  or  bladder  or  vagina.  The  teeth,  hair  and  pieces  of  bone  dis- 
charged in  rare  cases  from  the  urethra  or  rectum  are  usually  due  to  suppura- 
tion of  a  dermoid  cyst. 

5.  Rupture  of  the  Cyst  may  be  sudden,  as  from  a  fall  or  blow  or  other  in- 


948 


TUMORS   OF    THE   OVARY    AND   PAROVARIUM 


Fig.  759.     Section  from   Fibroma   of   Ovary,    shown 
in   Fig.    758    (lower   power). 


Fig.  760.     Same  section,  under  higher  magnification. 


Fig.   761.     Carcinoma    of    Ovary    originating    from    a 
papillary  cyst.     IvOw  power. 


Fig.  762.     Same    section,    under    higher    power. 


CYSTIC   TUMORS   OF   THE   OVARY 


949 


jury,  or  it  may  be  the  result  of  a  gradual  thinning  of  the  cyst  wall.  The  re^ 
suit  of  rupture  of  the  cyst  depends  on  the  quantity  and  quality  of  the  cyst 
contents.  In  unilocular  cysts  with  non-irritating  fluid  the  rupture  may  pro- 
duce no  severe  symptoms.  There  is  some  Aveakness  and  abdominal  pain  and 
marked  diuresis,  the  patient  sometimes  passing  several  gallons  of  urine  in 
twenty-four  hours.  The  abdomen,  which  was  before  prominent  from  the 
tumor,  becomes  flattened  and  lax.     The  physical  signs  change  from  those  of 


N 


Fi£.   763.      Solid,   medullary    ovarian    carcinoma,    showing   its  typical    nodular   appearance. 


encysted  fluid  to  those  of  free  fluid  (pages  197  and  201).  The  cyst  may  not 
refill,  and  if  no  inflammation  takes  place,  the  patient  recovers.  But  this  favor- 
able termination  takes  place  only  in  rare  cases.  In  the  great  majority  of 
cases  of  cyst,  rupture  causes  peritonitis,  which  may  be  very  severe  and  rap- 
idly fatal. 

Eupture  of  a  cyst  is  indicated  by  the  sudden  disappearance  of  the  tumor 
or  marked  diminution  in  its  size,  accompanied  with  evidences  of  free  fluid  in 


950 


TUMORS    OF    THE    OVARY   AXD   PAROYARrCM 


Fig.   764.     Cross  section  through   solid  ovarian  carcinoma  shown   in   Fig.    763. 


f^Tsp^—!^'    "yv"-^  .  "-.yN—  rf>-»  *r>  -■»%--.-'  «  ".'«'.?-, 


i^RV  -Jt-  T  J5«l\":-Ve/..c  .^-fJ  'O  . 


:'^h^jM.  ^:■^ 


Fig.  765.     Photomicrograph  of  Carcinoma  of  Ovary,  medullary  type. 


CYSTIC    TUMORS    OF    THE    OVARY 


951 


the  peritoneal  cavity  and  collapse  of  patient,  and  later  peritonitis  and  death. 
6.  Ascites.  A  small  amount  of  ascitic  fluid  may  be  present  with  many 
cysts,  but  a  large  quantity  is  rare  so  long  as  the  tumor  retains  its  normal  con- 
dition. Consequently  the  presence  of  considerable  ascitic  fluid  with  an  ova- 
rian cyst  becomes  of  diagnostic  importance.  The  ascites  may  of  course,  be  due 
to  some  heart  trouble  or  kidney  trouble  or  liver  trouble,  or  may  be  due  to  peri- 
toneal tuberculosis.    Aside  from  such  complications,  ascitic  fluid  is  indicative 


1 J 


6  ^,^ 


If'-' 


-Mi-'-^.^'' 


Fig.   766.      Carcinoma  of  Ovary,  primary  solid  tumor.         Fig.   767.      Same  section,   under  higher  magnification. 

of  some  serious  complications;  e.g.,  a  papillary  cyst,  especially  after  malignant 
change,  or  rupture  of  an  ordinary  cyst. 

7.  Intestinal  Obstruction.  This  may  be  caused  by  direct  pressure  of  the 
tumor  or  by  adhesions  which  contract  and  narrow  the  intestine.  It  is  of 
course  a  very  serious  complication  and  is  indicated  by  the  ordinary  symp- 
toms of  intestinal  obstruction  appearing  in  the  presence  of  an  ovarian  tumor. 


TREATMENT 

of  Ovarian  Cysts 

The  treatment  of  the  simple  cysts  of  the  ovary  is  symptomatic.  There  is 
no  method  of  affecting  these  little  cysts  directly  except  by  operation,  and  the 
symptoms  are  usually  not  severe  enough  to  Avarrant  operation.  Consequently, 
the  treatment  is  directed  toward  relieving  the  symptoms,  and  consists  of  the 
measures  recommended  under  chronic  pelvic  inflammation  for  relieving  the 


952 


TUMORS   OF    THE   OVARY   AND   PAROVARIUM 


same  symptoms.  If  the  symptoms  are  persistent  and  very  troublesome  in  spite 
of  all  minor  measures,  the  abdomen  may  be  opened  and  the  cysts  removed, 
saving  as  much  as  possible  of  both  the  ovaries. 

The  treatment  of  the  proliferating  cysts  and  dermoid  cysts  is  removal  by 
operation  as  soon  as  found,  if  the  condition  of  the  patient  will  permit. 

Ovarian  tumors  are  not  at  all  influenced  by  palliative  measures,  they  do 


Fig.  768.     Krukenberg  Tumor   of   Ovary. 


Fig.   769.     Same  specimen  shown  in  a  cross  section. 


not  stop  growing  spontaneously  and  they  tend  to  death  within  a  few  years. 
Consequently  they  should  be  removed  as  soon  as  found  or,  as  soon  as  the  pa- 
tient can  be  put  in  condition  for  the  operation.  Sometimes  the  patient  is  in 
such  a  weakened  condition  that  she  must  be  given  a  course  of  treatment  before 
operation.  Some  general  disease,  such  as  kidney  or  heart  or  lung  trouble,  may 
make  it  necessary  to  delay  the  operation  until  the  patient  can  be  put  in  better 
condition. 


SOLID    TUMORS    OF    THE   OVARY 


95J 


Then,  again,  the  patient  may  be  in  such  condition  that  a  radical  operation 
would  be  almost  certainly  fatal.  In  such  a  case  it  would,  of  course,  be  useless 
to  operate.  In  some  such  inoperable  cases  the  patient  may  be  rendered  tem- 
porarily more  comfortable  by  tapping  the  cyst  with  a  trocar  and  drawing  off 
the  fluid.  In  all  cases  of  proliferating  cysts,  however,  in  which  the  patient 
is  in  suitable  condition,  the  tumor  should  be  removed  by  operation. 


SOLID  TUMORS  OF  THE  OVARY 

Solid  tumors  of  the  ovary  are  rare.    They  comprise  only  about  five  per  cent 
of  all  ovarian  growths  that  come  to  operation. 


;    ^ 


.    -«# 


I . 


■iV  t    *S- 


ens' 


Fig.  770.  Carcinoma  of  ovary,  secondary — Kruk- 
enberg  tumor.  The  characteristic  "sickle"  cells  are 
well   shown. 


Fig.  771.  Krukenberg  tumor,  indicating  the  pri- 
mary growth  (in  the  stomach)  and  the  distribution 
of  the  secondary  grovyths  (both  ovaries,  right  kidne.v, 
pancreas,    and   sigmoid   flexure   of   the   colon). 


The  simple  tumors  are  fibromata  and  fibromyomata  (Figs.  758,  759  and 
760).  These  growths  are  infrequent  and  usually  small,  though  occasionally  one 
will  grow  to  weigh  ten  or  fifteen  pounds. 

Of  the  malignant  growths,  sarcoma  is  said  to  be  the  most  frequent.  It 
may  be  of  the  spindle  cell  or  round  cell  variety,  and  usually  grows  rapidly. 
As  a  rule  both  ovaries  are  affected  (Fig.  772,  773). 

Carcinoma  of  the  ovary  is  generally  secondary  to  a  papillary  cyst  (Fig. 
761,  762). 

Solid  primary  carcinomata  of  the  ovary  are  rather  rare.    Usually  they  rep- 


954 


TUMORS    OF    THE    OVARY    AND    PAR0VARIU:M 


resent  the  medullary  type  (Fig.  763).  They  are  of  a  soft  consistency  as  the 
result  of  degenerative  processes,  which  are  clearly  shown  on  the  cross  section 
of  such  a  growth  in  Fig.  764.  Microscopic  sections  (Figs.  766,  767)  confirm 
the  common  observation  that  these  carcinomata  often  show  an  adenomatous 
structure. 

A  very  large  percentage  of  ovarian  carcinomata,  however,  are  metastatic 
in  origin.  They  develop  secondarily  to  carcinoma  of  other  organs,  either  of 
uterus  and  tubes,  or  of  organs  lying  distantly  in  the  peritoneal  cavity,  such  as 
stomach,  intestines,  gall  bladder,  pancreas,  etc. 

It  is  probable  that  these  secondary  carcinomatous  growths  are  started  in 
the  ovaries  by  particles  which  have  become  detached  from  the  primary  car- 


Fig.  772.  Sarcoma  of  the  ovary,  secondary  to  a 
sarcoma  originating  in  a  uterine  fibromyoma.  Photo- 
micrograph, lower  power. 


Fig.  773.  Another  section  from  same  growth 
shown  in  Fig.  772.  The  sarcomatous  infiltration 
has  involved  a  corpus  albicans. 


cinoma  and  through  peristalsis  and  gravity  have  been  carried  to  the  ovaries 
deep  down  in  the  pelvis  (Fig.  771). 

It  is  this  fact  which  most  plausibly  explains  the  common  bilaterality  of  the 
solid  ovarian  cancers,  a  point  of  great  practical  importance  and  well  justifying 
the  demand  of  certain  authors  ahvays  to  remove  both  ovaries  even  if  only  one 
macroscopically  seems  aifected  by  a  maligant  groAvth. 

For  this  same  reason  it  becomes  imperative  in  all  cases  of  diagnosed  or  sus- 
pected bilateral  ovarian  carcinoma  to  search  most  carefully  for  a  possible 
primary  carcinoma  in  the  gastro-intestinal  tract  or  in  another  organ  within 


TUMORS    OF    THE   PAROVARIUM  955 

the  abdominal  cavity.  It  is  obvious  that  in  these  cases  operative  efforts  of 
necessity  must  prove  futile. 

Figs.  768,  769,  770  and  771  illustrate  a  special  and  rather  rare  type  of  such 
a  secondary,  metastatic  ovarian  carcinoma,  known  in  literature  as  a  Kruken- 
berg  tumor.  This  particular  growth,  a  carcinoma  suggesting,  however,  structur- 
ally in  certain  features  a  sarcoma,  is  characterized  by  peculiar  cells  with  an 
eccentrically  placed  nucleus.  These  ''Signet  Eing"  or  "Sickle"  cells  are  well 
sho-v\m.  in  the  photo  presented  in  Fig.  770. 

Owing  to  the  rarity  of  solid  tumors  of  the  ovary  and  the  absence  of  dis- 
tinctive symptoms,  the  diagnosis  is  usually  made  only  after  the  abdomen  is 
open. 

In  the  case  of  a  firm  mass  presenting  the  symptoms  and  signs  already  de- 
scribed for  a  small  ovarian  tumor  (except  fluctuation)  a  probable  diagnosis 
of  solid  tumor  of  the  ovary  may  be  made. 

The  treatment  for  every  solid  tumor  of  the  ovary  is  prompt  removal  by 
operation. 

TUMORS  OF  THE  PAROVARIUM 

The  tumors  of  the  parovarium  (broad  ligament  tumors)  are  almost  invaria- 
bly cysts  and  they  are  of  tAvo  kinds,  simple  cysts  and  papillary  cysts. 

The  simple  cysts  are  single  cysts  containing  clear  fluid  resembling  water. 
On  account  of  their  confined  position  they  produce  very  troublesome  symptoms 
while  still  small.  They  arise  from  various  parts  of  the  remains  of  the  Wolf- 
fian body  (parovarium,  paroophoron — Figs.  732,  733). 

The  proliferating  papillary  cysts  arise  also  from  the  remnants  of  the 
Woliffian  body  and  their  characteristic  is  the  development  of  papillary  growths 
in  the  interior  of  the  cyst,  which  fill  the  cyst  and  grow  through  its  wall, 
and  spread  to  the  peritoneal  surface  and  the  adjacent  organs  (uterus,  ovaries, 
intestines).  The  whole  pelvis  may  be  filled  Avith  these  warty  cauliflower 
growths  and,  having  spread  to  all  the  adjacent  structures,  they  often  give 
rise  to  an  erroneous  diagnosis  of  cancer.  " 

In  the  majority  of  cases  they  are  bilateral  and  usually  rupture  before  at- 
taining a  large  size.  Though  they  grow  rapidly  and  spread  to  adjacent  organs, 
where  they  implant  themselves  on  the  peritoneal  surfaces  and  grow  freely, 
they  do  not  have  the  fatal  infiltrating  and  destructive  tendency  of  malignant 
disease,  and  many  patients  recover  when  the  abdomen  is  opened  and  the  larger 
part  of  the  growth  removed.  Later  they  may  undergo  malignant  change,  and 
then  they  present  the  usual  characteristics  of  carcinomata. 

These  proliferating  papillary  cysts  arise  from  the  parovarium.  As  most 
parovarian  tubules  lie  in  the  broad  ligament,  the  papillary  cysts  are  usually 
broad  ligament  cysts.  But  they  may  also  arise  from  that  part  of  the  paro- 
varium which  is  prolonged  into  the  hilum  of  the  ovary.  It  is  from  that  loca- 
tion that  the  papillary  cysts  of  the  ovary  arise.  As  mentioned  before,  the 
papillary  cysts  of  the  ovary  are  usually  bilateral  and  present  all  the  charac- 


956 


TUMORS   OF    THE   OVAEY   AND   PAROVARIUM 


-A 


Periton 


..^i.„ '•..,  • 


Fig.   774.     A  Parovarian  Cyst   (broad  ligament  cyst)    of  the  left  side.     Notice  how  it  separates  the  layers   of 
the  broad  ligament  and  also  displaces  the  uterus.      (Kelly — Operative  Gynecology.) 


Fig.  775.  Parovarian  Cyst.  The  ovary  is  seen  intact  to  the  right.  Just  above  it  is  seen  the  severed 
uterine  end  of  the  tube,  which  lies  underneath  the  peritoneum  and  can  be  followed  down  to  the  fimbriated 
end  of  the  tube  seen  in  the  middle  of  the  picture. 


teristics  of  the  broad  ligament  papillary  cysts,  except  that  they  arise  from  the 
ovary  instead  of  from  the  broad  ligament.  They  are  supposed  to  arise  from 
the  remnants  of  Wolffian  tubules  lying  in  the  medullary  portion  of  the  ovary. 


TUMORS   OF    THE   PAROVARIUM 


957 


Symptoms  and  Diagnosis 

In  the  clinical  history  and  in  the  signs  obtained  by  examination,  broad 
ligament  tumors  resemble  ovarian  tumors  very  closely.  Practically  the  same 
symptoms  and  signs  which  serve  to  distinguish  an  ovarian  tumor  from  other 
diseases  serve,  also,  to  distinguish  a  broad  ligament  tumor  from  the  same 
diseases.  So  that  as  a  rule,  in  this  condition,  when  there  is  trouble  in  diag- 
nosis, the  difficulty  is  to  tell  whether  the  tumor  present  is  a  broad  ligament 
tumor  or  an  ovarian  tumor. 

The  characteristics  of  the  ordinary  parovarian  cyst,  or  ''broad  ligament 
cysts,"  as  they  are  usually  called,  are  as  follows: 

1.  They  grow  into  the  broad  ligament,  separating  its  layers  and  displacing 
the  adjacent  organs.  The  uterus  is  pushed  far  to  one  side  (Figs.  364,  774,  775, 
777),  and  the  tube  is  usually  stretched  over  the  cyst,  being  much  lengthened 


'■'s&i''"-^^ 


J 


..^ 


>y  . 


'«^.*  ' 


1^^ 


^.-•>- 


Fig.  776.     The  Wall  of  a  Simple  Parovarian  Cyst.     Its.  inner  surface  is  lined  by  a  single  layer  of  flattened 
epithelium.      There   are  no  secondary   cavities. 


and  flattened.  The  ovary  also  is  flattened  out  on.  the  surface  of  the  cyst. 
There  is  more  or  less  fixation  of  the  cyst  and  also  of  the  displaced  uterus. 
They  may  grow  under  the  peritoneum  and  separate  it  from  the  rectum,  blad- 
der and  abdominal  wall. 

2.  They  produce  serious  symptoms  much  earlier  than  ovarian  cysts.  This 
is  due  to  their  being  confined  Avithin  the  broad  ligament  and  the  pelvis,  and 
hence  making  serious  pressure  on  surrounding  organs  while  they  are  still 


958 


TUMORS   OF    THE    OVARY    AND   PAROVARIUM 


small.    For  this  reason  they  cause  more  pelvic  pain  and  more  menstrual  dis- 
turbance than  ovarian  cysts  of  the  same  size. 

The  papillary  cyst,  after  rupture  and  spread  of  its  papillary  growths,  may 
produce  a  clinical  picture  very  much  resembling  tubercular  peritonitis  or 
chronic  pelvic  inflammation.  It  then  usually  gives  rise  to  marked  ascites,  and 
the  fluid  returns  repeatedly  after  tapping. 


Fig.   m .     Large   Croad   Ligament   Cyst,   showing  the   stretching  of   the   Fallopian   tube  and   the  displacement 

of  the  uterus. 


The  rapidity  of  growth  of  the  broad  ligament  tumors  depends  somewhat  on 
the  character  of  the  groAvth.  Those  of  slow  growth  are  usually  simple  cysts 
(Fig.  776).  The  papillary  cysts  grow  rapidly  at  the  last,  though  the  growth 
may  be  slow  while  confined  within  the  broad  ligament. 


TUMORS    OF    THE   PAROVARIUM  959 


Treatment 


The  treatment  for  broad  ligament  tumors  is  the  same  as  for  ovarian  tu- 
mors— that  is,  removal  by  abdominal  section.  In  some  cases  of  simple  cyst, 
very  low  in  the  pelvis,  with  the  patient  in  bad  condition,  it  is  better  to  open 
the  cyst  from  below,  drain  away  the  fluid  and  pack  the  cavity,  keeping  the 
wound  open  until  the  cavity  is  obliterated,  the  same  as  in  the  treatment  of 
pelvic  abscess.  Some  cases  may  be  permanently  cured  in  this  way  with  much 
less  danger  than  by  abdominal  section. 

Ordinarily,  however,  the  preferable  operation  is  abdominal  section.  The 
operation  for  a  parovarian  cyst  is  somewhat  more  difficult  than  for  an  ova- 
rian cyst  owing  to  the  fact  that  the  parovarian  growth  lies  between  the 
layers  of  the  broad  ligament.  This  necessitates  opening  the  broad  ligament 
to  extract  the  cyst  and  also  necessitates  careful  closure  of  the  remaining  broad 
ligament  cavity  to  prevent  oozing  or  secondary  hemorrhage. 


CHAPTER  XIII 

MALFORMATIONS 

Malformations  are  caused  by  errors  in  development.  The  growth  of  an  or- 
gan may  be  simply  arrested  or  it  may  grow  in  the  wrong  way.  In  either 
case  there  results  a  malformation.  Most  genital  deformities  are  due  to  par- 
tial arrest  of  development.  To  understand  these  malformations,  it  is  neces- 
sary to  understand  something  about  the  development  of  the  organs. 

POINTS  IN  DEVELOPMENT 

The  first  structures  indicative  of  the  genito -urinary  organs. are  the  Wolf- 
fian ducts,  which  appear  in  the  embryo  about  the  fifteenth  day,  and  the 
WolfSan  bodies,  which  appear  the  eighteenth  day.  These  structures  repre- 
sent the  future  kidneys  and  genital  apparatus.  They  lie  on  either  side  of 
the  median  line. 

During  the  fourth  week  another  duct  appears  near  the  Wolffian  body  of 
each  side.  These  are  the  Muellerian  ducts.  The  AVolffian  ducts  go  to  form 
the  excretory  ducts  of  the  genital  apparatus  in  the  male.  The  Muellerian 
ducts  go  to  form  the  excretory  ducts  of  the  genital  apparatus  in  the  female. 
A  part  of  the  Wolffian  body  of  each  side  finally  forms  the  genital  gland  of 
that  side,  i.  e.,  the  ovary  in  the  female  and  the  testicle  in  the  male. 

At  the  end  of  the  first  month  the  middle  part  of  each  Wolffian  body  shows 
thickening  and  proliferation,  resulting  in  the  formation  of  elevated  bands 
called  "genital  ridges."  These  are  the  earliest  traces  of  the  genital  glands. 
For  a  few  days  they  remain  indifferent.  Very  soon,  however,  a  difference  in 
the  two  sexes  is  noticed.  The  primitive  female  gland  "possesses  a  large  num. 
ber  of  the  primitive  sexual  cells  and  evidences  a  tendency  of  its  elements  to 
arrange  themselves  into  groups,  in  which  the  large  primitive  ova  become  cen- 
tral figures."  The  primitive  male  gland,  on  the  other  hand,  shows  a  tendency 
to  the  formation  of  a  net-work  of  cell  cords— the  forerunners  of  the  semi- 
niferous tubules.  "Microscopic  examination  of  the  sexual  primitive  glands 
even  at  the  end  of  the  fifth  Aveek  is  capable  of  distinguishing  the  future  sex 
of  the  being. "  In  a  short  time  there  is  a  difference  in  the  gross  appearance 
of  the  gland,  with  a  difference  in  the  arrangement  of  the  ducts. 

The  parts  played  by  the  Wolffian  ducts  and  Muellerian  ducts  differ  in  the 
two  sexes.  In  the  female  the  Muellerian  ducts  are  the  most  important.  The 
lower  portions  of  the  ducts  of  Mueller  become  fused  and  form  the  vagina  and 

960 


POINTS   IN   DEVELOPMENT 


961 


uterus,  and  the  upper  portions  remain  separated  and  form  the  Fallopian 
tubes  (Figs.  778,  779,  781).  The  lower  end  of  the  canal  (future  vagina) 
formed  by  the  fused  Muellerian  tubes  is  closed  at  first.  Later  the  lower  part 
of  the  septum,  which  shuts  off  this  canal  from  the  uro-genital  sinus,  breaks 
do■\^^l,  permitting  the  canal  (vagina)  to  communicate  with  the  uro-genital 
sinus.  If  this  septum  fails  to  break  do^vn,  imperforate  hymen  results  (Figs. 
209,  210).  The  very  end  of  the  other  extremity  of  the  Muellerian  duct  is  usu- 
ally represented  by  a  miniature  cyst  attached  to  one  of  the  fimbrian  and 
called  the  ''hydatid  of  Morgagni"  (Fig.  733). 

The  Wolffian  body  forms  the  ovary  and  also  contributes  the  transverse 
tubules  of  the  parovarium.     The  upper  part  of  the  "Wolffian  duct  remains  as 


JFimbria. 
/ 


Genital  process 
\penis  or  ciiiorh). 


Labium        Labium         Barthoiin's 
iiiiijor.  minor.  gland. 


Fig.  778.     Diagram  Representing  the  Indif-  Fig.  ITi.     Diagram  Illustrating  the   Changes  that  take 

ferent   Stage  in  the   Development  of  the   Gen-  place  in  the  Development  of  the  Female   Generative   Or- 

erative    Organs.       (Piersol,    after    Thompson —  gans.      (Piersol,   after   Thompson — American   Textbook   of 

American    Textbook    of    Obstetrics.)  Obstetrics.) 


the  ''head  tube"  of  the  parovarium  (Fig.  733).  The  lower  part  of  the  Wolf- 
fian duct  sometimes  remains  in  whole  or  in  part,  and  is  then  kno^vn  as 
"Gartner's  duct"  (Fig.  733).  These  parovarium  tubules  are  all  atrophic 
structures  of  but  little  importance.  The  ovary  is  the  important  organ 
formed  from  the  Wolffian  body  in  the  female. 

In  the  male  the  Wolffian  tubules  and  Wolffian  duct  contribute  the  im- 
portant system  of  excretory  tubes  represented  by  the  vas  deferens  and  the 
epididymis,  while  the  Muellerian  duct  is  atrophic,  its  ends  alone  remaining. 
Its  outer  end  forms  the  "hydatid  of  Morgagni,"  closely  connected  with  the 
epididymis,  and  its  inner  end  forms  the  "sinus  pocularis,"  or  "uterus  mas- 


962 


MALrORMATIONS 


culinus,"  opening  into  the  prostatic  portion  of  the  urethra  (Figs.  778,  780). 
External  Genitals  (Fig.  782).  ''Until  the  ninth  or  tenth  week  the  ex- 
ternal genitals  afford  no  positive  information  as  to  sex" — they  are  indiffer- 
ent. They  then  begin  to  differentiate  and  ''usually  by  the  end  of  the  third 
month  the  external  sexual  organs  are  characteristic  beyond  doubt."  Up  to  the 
sixth  week  the  external  openings  of  the  intestine  and  of  the  urinary  apparatus  are 
received  within  a  common  cloacal  recess  whose  recto-uro-genital  orifice  is 
surmounted  by  a  small  conical  elevation,  the  "genital  tubercle."  The  lower 
and  posterior  surface  of  the  genital  tubercle  is  divided  by  a  furrow— the 
"genital  groove"— bounded  by  thickened  edges  called  the  "genital  folds." 
Gradually  a  septum  develops,  separating  the  rectal  opening  from  the  genito- 


Epididy  litis. 


Uracil 


didym 


Fig.  780.     Diagram  Illustrating  the   Changes  that  Take  Place  in  the   Development  of  the  Male   Generative 
Organs.     (Piersol,  after  Thompson — American  Textbook  of  Obstetrics.) 


urinary  opening.    The  "genital  tubercle"  forms  the  clitoris  and  the  "genital 
folds"  form  the  labia. 

The  vestibule  is  formed  by  the  cloaca  or  common  opening  of  the  intes- 
tinal tract  and  urinary  tract  in  the  early  embryo.  The  perineum,  develop- 
ing, separates  the  rectum  from  this  common  vestibule.  And  the  septum  (hy- 
men) closing  the  end  of  the  rudimentary  vagina  (fused  Muellerian  ducts) 
breaks,  allowing  the  vagina  to  open  into  the  vestibule.  This  opening  through 
the  septum  varies  much  in  size,  shape  and  situation,  giving  the  various  forms 
of  opening  found  in  the  hymen  (Fig.  193).  It  is  usually  small,  and  roughly 
crescentic  in  shape. 

The  vagina  is  formed  by  the  fusion  of  the  lower  portions  of  the  two  Muel- 
lerian ducts  and  the  absorption  of  the  longitudinal  septum  between  the 
cavities.     The  uterus  is  formed  by  the  fusion  of  the  middle  portions  of  the 


POINTS   IN   DEVELOPMENT 


963 


two  Muelleriaii  duets  and  the  absorption  of  the  septum  between  the  cavities. 
The  Fallopian  tube  of  each  side  is  formed  by  the  upper  portion  of  the 
Muellerian  duct  of  that  side.  The  ovary  of  each  side  is  formed  from  a 
portion  of  the  Wolflian  body  of  that  side.     The  parovarium  consists  of  the 


Fig.  7S1.  Diagrammatic  Representation  of  the  Development  and  Malformations  of  the  Uterus. 
I.  Stowing  the  different  stages  in  the  union  of  the  Muellerian  ducts  to  form  the  uterus  and  vagina  and 
Fallopian  tubes.  2.  Uterus  unicornis.  3.  Uterus  bicornis.  4.  Uterus  septus.  5.  Uterus  duplex.  (Gilliam — 
Practical  Gynecology.) 


''transverse  tubules,"  which  are  formed  from  the  Wolffian  body,  and  the 
"head  tube,"  which  is  formed  from  the  WolfEan  duct.  The  paroophoron, 
lying  in  the  broad  ligament  near  the  parovarium,  is  the  atrophic  remains 
of  the  lower  segment  of  the  Wolffian  body. 


964 


MALFORMATIONS 


Fig.  782.  Development  of  the  External  Genitals  (after  Ecker-Ziegler  models).  A,  indifferent  stage 
(eighth  week);  gt,  genital  tubercle;  gr,  genital  ridge;  gf,  genital  fold;  gg,  genital  groove.  B,  female  type;' 
cl,  clitoris;  /.  maj.,  labia  majora;  v,  vestibule;  /.  min.,  labia  minora;  vag.,  vagina;  p.,  perineum.  C,  male 
type;  gp.,  glans  penis;  pr.,  prepuce;  r,  raphe;  s.,  scrotum. 


ANOMALIES  OF  DEVELOPMENT 

The  more  common  anomalies  of  development  are  as  follows : 

1.  The  septum  between  the  embryonic  vagina  and  the  sinns  uro-genitalis 
may  fail  to  break  down,  in  which  case  there  results  imperforate  hymen  (Figs. 
209,  210). 

2.  More  rarely,  perfect  canalization  does  not  take  place  in  the  fused 
Muellerian  cords  (each  of  which  develops  a  central  canal  and  becomes  a  Muel- 


ANOMALIES    OF   DEVELOPMENT  965 

leriaii  duct),  resulting  in  a  closed  place  at  some  point  in  the  canal,  giving 
atresia  of  vagina  or  atresia  of  cervix  (Figs  357,  366).  In  very  rare  eases 
all  of  the  lower  part  of  the  fused  cords  fails  of  canalization,  causing  absence 
of  vagina  (Fig.  212). 

3.  The  septum  which  normally  separates  the  urinary  tract  (urethra)  from 
the  vagina  may  be  defective,  forming  the  anomaly  known  as  hypospadias. 

4.  The  septum  between  the  two  fused  Muellerian  ducts  may  persist  all 
the  way  to  the  hymen,  in  which  case  there  exists  double  vagina  (Figs.  213, 
214). 

5.  The  septum  may  persist  into  the  uterine  portion  of  the  Muellerian 
tract,  forming  a  uterus  septus   (Fig.  781-4). 

6.  The  middle  portions  of  the  Muellerian  ducts  may  fail  to  fuse,  giving  a 
double  uterus  (uterus  didelphys)  (Fig.  781-5). 

7.  They  may  fuse  only  imperfectly,  giving  a  uterus  with  rudimentary 
horns.  There  may  be  either  two  well-marked  horns  (uterus  bicornis)  (Fig, 
781-5),  or  a  fairly  well-developed  uterus  with  one  rudimentary  horn  (Figs. 
385,  781-5). 

8.  The  Wolffian  duct  may  persist  to  some  extent,  giving  a  duct  lying 
alongside  the  vagina  called  Gartner's  duct  (Figs.  732,  733).  This  may  extend 
all  the  way  along  the  vagina  and  open  near  the  hymen,  or  there  may  be  only 
remnants  of  the  tube  here  and  there.  These  remnants  sometimes  develop  so 
as  to  form  small  vaginal  cysts.  Such  cysts  are  situated  in  the  vaginal  wall 
along  the  course  of  the  atrophic  Wolffian  duct. 

The  above  are  the  principal  gross  developmental  anomalies  ordinarily 
met  with.  There  are  many  other  rarer  anomalies,  of  which  lack  of  space 
prevents  mention.  These  vary  in  each  organ  all  the  way  from  slight  modi- 
fication to  complete  absence.  The  ovary  is  probably  the  least  frequently  af- 
fected by  anomalies,  and  yet,  as  rare  as  they  are,  they  have  produced  many 
surprises  in  abdominal  work,  especially  in  the  cases  of  pregnancy  foUomng 
the  supposed  complete  removal  of  both  ovaries.  This  means,  of  course,  that 
some  ovarian  tissue  remams,  and  it  is  usually  said  to  be  a  "third  ovary." 
While  the  development  of  three  normal  ovaries  is  not  impossible,  the  condi- 
tion present  in  the  eases  under  consideration  is,  as  a  rule,  ''lobulation"  of 
the  ovary  of  one  or  both  sides,  and  not  the  presence  of  a  complete  third 
ovary.  The  lobulated  ovary  may  show  only  a  marked  constriction,  or  it 
may  be  divided  into  two  or  three  or  many  separate  lobules,  with  considerable 
space  between  various  lobules.  Bovee  mentions  a  case  of  his  in  which  the  ovary 
of  each  side  was  represented  simply  by  numerous  small  particles  of  ovarian 
tissue  scattered  over  a  large  area  of  the  posterior  surface  of  the  broad  liga- 
ment, and  resembling  verrucal  excrescences.  It  is  evident  that  in  such  a 
case  some  outlying  nodules  of  various  tissue  would  almost  certainly  be 
missed,  especially  if  obscured  by  an  inflammatory  exudate. 


966  MALTORMATIOXS 

The  malformations  most  commonly  requiring  treatment  are: 
Imperforate  Hymen. 
Atresia  of  Vagina. 
Double  Vagina. 
Malformations  of  Uterus. 
Pseudoliermapliroditism. 

IMPERFORATE  HYMEN 

The  origin  of  this  malformation  has  just  been  explained.  The  condition 
causes  no  disturbance  until  puberty.  After  puberty  there  is  a  collection  of 
menstrual  blood  back  of  the  imperforate  hymen.  This  gradually  increases 
in  amount  and  distends  the  vagina.  If  the  obstruction  is  not  relieved,  there 
is  gradual  dilation  of  the  uterus  (Fig.  210)  and  even  of  the  Fallopian  tubes 
(Fig.  211),  forming  a  cystic  mass,  the  contents  of  which  are  blood  and  the 
walls  of  which  are  formed  by  the  vagina  and  uterus. 

The  symptoms  are  characteristic.  At  the  age  of  puberty  no  menstru- 
ation appears,  but  about  every  four  weeks  the  patient  has  a  spell  of  feeling 
ill,  with  pain  in  the  lower  abdomen  and  the  usual  disturbances  accompany- 
ing menstruation.  The  mother  supposes  that  the  girl  is  going  to  menstruate, 
but  there  is  no  flow.  This  is  repeated  month  after  month.  As  the  collection 
of  blood  increases,  the  pain  and  disturbance  become  more  marked,  the 
patient's  health  begins  to  suffer,  and  a  tender  mass  appears  in  the  lower 
abdomen.  Finally  the  patient  becomes  so  sick  that  the  physician  makes  a 
local  examination.  He  finds  that  there  is  no  vaginal  opening  (Fig.  209), 
but  instead  there  is  a  fluctuating  mass  occupying  the  position  of  the  vagina 
and  uterus   (Figs.  210,  211). 

The  treatment  is  crucial  incision  of  the  distended  hymen,  and,  if  the 
membrane  is  thick,  excision  of  the  most  of  it.  The  cavity  above  should  be 
washed  out  wdth  normal  saline  solution  and  then  packed  with  sterile  gauze. 
Great  care  is  necessary  to  prevent  infection.  The  decomposing  blood  that 
necessarily  remains  along  the  oralis  of  the  cavity  favors  the  rapid  growth 
of  pus  germs,  and,  though  the  operation  is  a  simple  one,  patients  have  died 
from  it,  or  rather  from  the  infection  following. 

ATRESIA   OF   VAGINA 

The  method  of  origin  of  this  malformation  has  been  explained.  The 
condition  may  vary  all  the  way  from  a  thin  septum  blocking  the  canal  to 
complete  absence  of  the  canal.  The  external  genitals  and  hymen  may  be 
normal.  On  making  the  vaginal  examination,  an  obstruction  is  met  with  at 
some  point  in  the  vagina.  If  there  is  a  collection  of  menstrual  blood  back 
of  the  septum,  fluctuation  may  be  detected.  Digital  examination  per  rectum 
Avill  give  some  idea  of  the  extent  of  the  atresia  and  the  amount  of  blood 


DOUBLE  VAGINA  967 

behind  it.  If  the  patient  is  well  past  the  age  of  puberty,  and  there  is  no 
fluid  above  the  atresia,  the  probability  is  that  the  uterus  is  anomalous,  so 
much  so  that  menstruation  could  not  come  on  even  though  the  obstruction 
in  the  vagina  were  removed.  So,  before  undertaking  an  operation  for  mak- 
ing a  vaginal  canal,  recto-abdominal  examination,  under  anesthesia  if 
necessary,  should  be  made  to  establish  the  size,  shape  and  probable  develop- 
ment of  the  uterus.  In  cases  of  apparent  absence  of  the  uterus,  recto- 
vesical examination  (see  page  132)  may  be  of  assistance  in  locating  a  small 
nodule  in  the  situation  of  the  uterus. 

The  treatment  depends  on  the  circumstances  of  the  case.  If  only  a  thin 
septum  is  present  it  should  be  treated  practically  the  same  as  an  imperforate 
hymen — i.  e.,  incised,  to  let  out  the  blood,  and  then  partially  or  wholly  ex- 
cised. If  a  considerable  proportion  or  the  whole  of  the  vaginal  canal  is 
missing,  the  treatment  requires  extended  operative  measures  according  to 
the  special  conditions  present.  It  may  be  necessary  to  build  up  nearly  a 
whole  new  vagina. 

Acquired  Atresia.  A  considerable  proportion  of  the  cases  of  marked 
stenosis  of  the  vagina,  amounting  almost  to  atresia,  are  acquired.  Such  a 
condition  may  result  from  injuries  in  childhood  or  inflammation,  particu- 
larly the  gonorrheal  vaginitis  of  childhood,  and  severe  inflammations  fol- 
lowing the  exanthemata.  Congenital  syphilis  also  may  cause  the  same,  fol- 
lowing severe  ulceration.  In  later  life,  scar-tissue  resulting  from  injuries 
in  labor  is  the  most  frequent  cause  of  narrowings  in  the  canal  and  bands, 
and  constrictions  and  distortions.  Other  causes  in  the  adult  are  syphilitic 
ulceration,  injuries  and  severe  destructive  inflanmiations.  A  pessary  left 
in  the  vagina  for  several  years  may  lead  to  such  a  result.  In  rare  cases 
even  complete  atresia  may  result  from  some  one  of  these  causes.  The  atrophic 
vaginitis  or  ''adhesive  vaginitis"  of  old  age  (senile  vaginitis)  leads 
to  adhesion  of  the  Avails  of  the  vagina  and  stenosis  and  partial  obliteration 
of  the  canal  (see  page  468).  The  treatment  for  acquired  stenosis  or  atresia 
of  the  vagina  is  practically  the  same  as  for  the  congenital.  The  acquired 
form;  however,  is,  when  extensive,  likely  to  be  more  difficult  of  satisfactory 
treatment  on  account  of  the  large  amount  of  scar-tissue  in  the  vicinity. 

DOUBLE   VAGINA 

This  consists  usually  simply  in  a  longitudinal  septum  dividing  the 
v-agina  into  two  canals  (septate  vagina).  The  vagina  with  entirely  separate 
walls  is  a  much  rarer  condition.  The  longitudinal  septum  is  the  persisting 
fused  wall  of  the  two  Muellerian  ducts,  as  already  pointed  out.  It  may 
extend  the  whole  length  of  the  vagina,  giving  two  openings  at  the  vestibule, 
and  half  the  cervix  in  each  upper  end  (Figs.  213,  214).  On  the  other  hand, 
it  may  consist  simply  in  a  septum  extending  part  way.  Even  when  the 
septum  extends  the  full  length  of  the  vagina,  one  canal  is  usually  so  muck 


968  MALFORMATIONS 

smaller  than  the  other  and  placed  so  far  to  one  side  that  it  does  not  interfere 
Avith  coitus  or  pregnancy.  In  fact  the  opening  of  one  canal  may  be  so  flat- 
tened out  at  the  side  of  an  apparently  normal  vaginal  opening  that  it  is 
not  noticeable  except  on  very  close  inspection.  In  such  a  case,  however, 
when  the  slit  beside  the  vaginal  opening  is  noticed,  further  examination  may 
reveal  a  rudimentary  canal  of  considerable  size,  sometimes  almost  as  large 
as  the  patulous  one  (see  page  222).  At  the  upper  part  of  each  vagina  is 
one-half  of  the  cervdx.  When  labor  takes  place  in  a  case  of  double  vaginal 
canal,  the  septum  is  likely  to  be  torn,  partially  or  completely,  converting 
the  two  canals  into  one.  Portions  of  the  septum  may  remain  as  a  partial 
septum  at  the  upper  part  of  the  vagina  or  as  irregular  bands  and  tags.  The 
writer  recalls  one  case  of  septate  vagina  and  uterus  seen  in  the  first  preg- 
nancy. The  patient  passed  through  labor  without  particular  incident,  except 
that  the  cervix  (haK  cervix)  was  very  slow  in  dilating.  The  lower  part  of 
the  vaginal  septum  near  the  vaginal  entrance  was  torn,  but  the  greater  part 
remained  and  seemed  to  occasion  no  trouble."  Later,  the  patient  returned 
to  the  hospital  with  gonorrhea  affecting  the  vaginal  and  uterine  cavity  of 
each  side.  Still  later,  the  writer  was  obliged  to  euret  both  uterine  cavities. 
The  treatment  of  double  vagina  is  simple.  If  the  septum  is  causing  any 
obstruction  or  disturbance,  it  is  divided  or,  better  still,  largely  excised,  so 
that  the  two  vaginal  canals  are  converted  into  one. 


MALFORMATIONS  OF  THE  UTERUS 

Double  Uterus.  The  malformation  may  consist  simply  of  a  partial  or 
complete  septum  in  an  otherwise  normal  uterus  (uterus  septate.  Figs.  348, 
781-4),  or  a  rudimentary  horn  with  a  nearly  normal  uterus  (Fig.  385),  or  a 
uterus  with  a  body  divided  into  two  horns  (uterus  bicornis,  Fig.  781-5),  or 
a  double  uterus,  with  the  body  and  cervix. of  one  side  separate  from  the  body 
and  cervix  of  the  other  side  (uterus  didelphys,  (Fig.  781-5),  or  a  ''unicorn 
uterus" — i.  e.,  uterus  made  up  of  Muellerian  duct  of  one  side  only,  the  other 
being  absent  or  nearly  so  (Fig.  781-5).  The  most  severe  grades  of  deformity 
are  very  rare,  though  they  are  to  be  thought  of  in  the  diagnosis  in  puzzling 
cases.  A  septum  in  an  otherwise  normal  uterus  is  discovered  only  by  intra- 
uterine manipulation,  such  as  curetment  or  the  introduction  of  the  hand  after' 
labor  for  the  removal  of  adherent  placenta  or  for  other  reasons. 

No  treatment  for  double  uterus  is  required  ordinarily,  Avith  the  excep- 
tion of  the  precaution,  when  curetting  the  uterus,  to  be  certain  that  both 
cavities  are  clear.  It  is  appreciated,  of  course,  that  in  this  connection,  and 
also  in  double  uterus,  pregnancy  may  take  place  in  each  of  the  two  cavities, 
and  at  different  times  producing  various  surprising  results. 

Rudimentary  Horn.  The  uterine  malformation  of  most  practical  in- 
terest is  that  of  a  rudimentary  horn  with  an  othermse  nearly  normal  uterus. 
This  is  not  so  very  infrequent  and  many  are  the  diagnostic  difficulties  that 


PSEUDOHERMAPHRODITISM  969 

result  therefrom.  Such  a  rudimentary  horn  extends  outward  from  the 
mam  body  of  the  uterus,  and  receives  at  its  outer  extremity  the  attachment  of 
the  Fallopian  tube  and  round  ligament  of  that  side.  The  point  of  attachment 
of  the  round  ligament  is,  in  some  cases,  the  only  decisive  gross  evidence  as  to 
whether  the  mass  in  question  is  an  enlarged  Fallopian  tube  or  a  rudimentary 
horn  of  the  uterus.  The  cavity  of  the  rudimentary  horn  may  be  complete,  ex- 
tending all  the  way  from  the  Fallopian  tube  to  the  main  cavity  of  the  uterus,  or 
it  may  be  only  partial,  being  absent  at  some  part  (Fig.  385),  or  the  cavity  may 
be  entirely  absent,  the  horn  existing  merely  as  a  musculo-fibrous  cord  connect- 
ing the  Fallopian  tube  and  round  ligament  with  the  uterus.  Most  of  the  trouble 
resulting  from  a  rudimentary  horn  comes  from  infection  in  it  or  pregnancy 
in  it  (Figs.  384,  385). 

The  symptoms  and  differential  diagnosis  and  treatment  are  the  same  as  for 
similar  affections  of  the  Fallopian  tube,  with  the  following  special  points : 

1.  The  mass  is  usually  connected  to  the  uterus  by  a  much  broader  at- 
tachment. 

2.  There  is  more  enlargement  of  the  uterus  and  distortion  of  its  cavity. 

3.  The  mass  may  become  much  larger  without  rupture  (if  pregnant)  or 
without  adhesions  (if  inflammatory). 

4.  There  may  be  a  communication  with  the  main  uterine  cavity.  In  most 
cases  the  condition  is  not  thought  of  until  found,  during  the  course  of  an 
operation  for  what  was  supposed  to  be  some  one  of  the  more  common  affec- 
tions. Even  when  thought  of,  a  diagnosis  is  rarely  possible  (except  in  an 
examination  under  anesthesia),  for  it  produces  the  symptoms  and  signs  of 
more  common  conditions,  and  the  trouble  is  naturally  supposed  to  be  some 
one  of  these  more  common  affections.  In  some  cases,  however,  there  are 
anomalous  symptoms  or  signs  that  make  diagnosis  difficult  and  doubtful,  and 
arouse  suspicion  of  this  malformation.  Sometimes  there  is  decided  resemblance 
to  a  fibroid.  The  author  recalls  one  such  case.  The  symptoms  and  signs  were 
anomalous  and  puzzling.  He  made  a  diagnosis  of  probable  fibroid  with  com- 
plications. Operation  revealed  a  rudimentary  uterine  horn,  with  the  remains' 
of  an  early  pregnancy  in  it.    There  was  no  fibroid. 

PSEUDOHERMAPHRODITISM 

A  true  hermaphrodite  is,  according  to  Ahlf eld's  definition,  ''an  individual 
with  functionating  active  glands  of  both  sexes,  provided  with  excretory  ducts." 
No  such  case  has  been  reported  in  which  the  diagnosis  has  been  fully  accepted, 
though  there  is  considerable  dispute  among  authorities  concerning  some.  Sev- 
eral cases  have  been  recorded  in  which,  among  other  anomalies,  there  were 
glands  that  on  microscopic  examination  presented  some  of  the  characteristics  of 
both  ovary  and  testicle.  But  that  condition  does  not  constitute  a  double  set  of 
glands  and  excretory  ducts. 

A  pseudohermaphrodite  is  an  individual  of  one  sex  presenting  some  of  the 


970 


MALFORMATIONS 


local  characteristics  of  the  other  sex.  Many  such  cases  have  been  recorded  and 
not  a  few  of  them  have  presented  a  most  difficult  problem  in  regard  to  the 
diagnosis  of  the  sex.  The  individual  himself  (or  herself,  as  the  case  may  be) 
does  not  seem  to  be  able  to  help  much  in  determining  the  real  sex  in  the  most 
difficult  cases.  Neugebauer  was  able  to  collect  942  cases  of  pseudohermaphro- 
ditism. In  at  least  41  of  the  pseudohermaphrodites  the  true  sex  was  positively 
determined  only  after  abdominal  section,  though  in  only  four  cases  was  the 
operation  undertaken  specifically  for  diagnostic  purposes.  Numerous  cases  are 
recorded  where  the  individual  dressed  and  lived  for  many  years  as  a  man  or  as 
a  woman,  and  then  ascertained  that  the  real  sex  was  the  opposite  one.  The  most 
celebrated  case,  perhaps,  is  that  of  Carl  Hohmann,  a  masculine  pseudoher- 


/    ' 


Fig.  783.  Male  Pseudohermaphroditism.  The  ap- 
pearance of  the  external  genitals  in  marked  hypo- 
spadias. 


Fig.  784.  A  section  explanatory  of  Fig.  783. 
B^  bladder;  R,  rectum;  P,  penis  with  lower  urethral 
wall  absent;  H,  abnormal  condition  constituting  hy- 
pospadias and  requiring  a  careful  examination  to 
determine  the  sex  of  the  child;  X,  sinus  pocularis, 
enlarged  and  opening  on  perineum,  and  conse- 
quently likely  to  be  mistaken  in  the  newborn  for  a 
vagina. 


maphrodite,  who  from  infancy  to  the  age  of  forty-six  years  was  considered  a 
female  and  lived  as  such.  The  true  sex  being  then  ascertained  he  assumed 
male  attire  and  married  as  a  man.  The  space  available  is  not  sufficient  to  per- 
mit the  subject  of  pseudohermaphroditism  to  be  taken  up  in  an  extended  way. 
It  is  sufficient  to  mention  some  of  the  more  practical  points. 

When  a  child  presents  any  anomaly  of  the  genital  organs,  a  most  careful 
examination  should  be  made  and  all  the  possibilities  considered,  in  order  to 
determine  positively  the  real  sex.     Steps  in  the  development  of  the  external 


PSEUDOHERMAPHRODITISM  971 

genitals  are  sho-^^ai  in  Fig.  782.  Most  of  tlie  pseudoliermaplirodites  are  really 
males  (have  testicles  in  the  abdomen  or  scrotum),  the  resemblance  to  the  fe- 
male external  genitals  being  due  to  some  form  of  hypospadias  accompanied 
with  an  abnormal  opening  or  pocket  that  is  mistaken  for  a  vagina  (Figs.  783, 
784,  707).  The  principal  anomaly  in  female  pseudohermaphrodites,  that  causes 
some  resemblance  to  the  male  sexual  organs,  is  hypertrophy  of  the  clitoris 
(Fig.  250),  accompanied  with  adhesion  of  the  labia  minora  or  labia  majora 
over  the  vaginal  opening  (Fig.  208),  or  with  imperforate  hymen  (Fig.  209), 
or  with  labial  hernia  (Fig.  262),  or  hydrocele  or  other  labial  swelling  covering 
the  vestibule. 

Tn  some  cases  the  positive  determination  of  the  sex  is  very  difficult  and 
may  even  be  impossible  except  by  abdominal  section.  The  general  rule  in 
€ases  of  doubt  is  to  class  the  pseudohermaphrodite  as  a  male  until  unmistak- 
able evidence  of  the  oi)posite  sex  appears.  This  will  avoid  a  mistake  in  a 
great  majority  of  instances.  In  the  case  of  four  supposed  female  pseudo- 
hermaphrodites who  were  subjected  to  abdominal  section,  three  of  them 
proved  to  be  males. 


CHAPTER  XIV 

DISTURBANCES  OF  FUNCTION 

Not  only  those  disturbances  wliich.  are  designated  as  ''functional"  be- 
cause no  organic  lesion  is  apparent,  but  also  tlie  disturbances  of  function  due 
to  various  organic  diseases — tliat  is,  all  ''disturbances  of  function,"  whether 
accompanied  by  evident  organic  disease  or  not,  shall  be  considered  in  this 
chapter.  These  conditions  are,  of  course,  only  symptoms.  They  are  not  dis- 
eases and  must  not  be  taken  to  constitute  a  diagnosis.  They  are  only  indi- 
cations of  some  disease,  and  the  physician  must  determine  the  nature  of  that 
disease  by  further  investigation. 

The  subjects  will  be  taken  up  as  follows: 
Disturbances  of  Menstruation. 

Points  in  Physiology  (Normal  Menstruation). 
Absence  of  Menstruation  (Amenorrhea). 
Scanty  Menstruation. 
Excessive  Menstruation  (Menorrhagia). 
Painful  Menstruation  (Dysmenorrhea). 
Irregular  Menstruation. 
Precocious  Menstruation. 
Vicarious  Menstruation. 
Disturbances  of  Sexual  Intercourse. 
Dyspareunia. 
Sexual  Impotence. 
Disturbances  of  Child-bearing. 

Sterility. 
Discharge  from  the  Genitals. 
Leucorrhea. 
Bloody  Discharge. 

POINTS  IN  PHYSIOLOGY  (NORMAL  MENSTRUATION) 

As  a  prelude  to  the  menstrual  disturbances  proper,  it  is  well  to  call  at- 
tention to  some  points  in  the  physiology  of  normal  menstruation. 

Menstruation  is  the  regular  periodic  discharge  of  blood  from  the  uterus, 
recurring  about  every  four  weeks  from  puberty  to  the  menopause,  except 
during  pregnancy  and  lactation.  This  definition,  however,  does  not  express 
all  there  is  of  menstruation.    The  menstrual  flow  is  simply  the  outward  sign 

972 


NORMAL    MENSTRUATION  973 

of  important  internal  changes,  and  we  must  inquire  what  these  internal  changes 
are  and  what  they  mean  in  the  life  of  the  woman. 

In  dealing  with  this  subject  there  must  be  taken  into  consideration  the 
following  three  phenomena: 

Puberty  and  the  beginning  of  menstruation. 

Menstruation  when  fully  established. 

The  menopause  or  ''change  of  life." 

1.  Puberty  and  the  Beginning'  of  Menstruation.  Puberty  is  the  period  at 
which  the  girl  matures  and  becomes  capable  of  child-bearing.  This  period 
is  marked  by  a  very  rapid  development  of  the  sexual  organs.  The  ovaries, 
uterus,  vagina  and  external  genitals  enlarge,  hair  appears  in  the  pubic  region 
and  in  the  axillae,  the  breasts  become  more  prominent,  the  pelvis  enlarges 
■and  the  whole  body  becomes  somewhat  larger  and  its  outlines  more  rounded 
and  graceful.  These  physical  changes  are  accompanied  by  mental  changes, 
which  are  indicated  by  modesty,  sexual  desire  and  allied  phenomena. 

These  changes  take  place"  usually  between  the  eleventh  and  sixteenth  years. 
When  the  proper  development  has  been  reached,  the  menstrual  flow  appears. 
This  flow  is  the  sign  that  development  has  taken  place  and  that  ovulation  has 
begun.  Ovulation,  no  doubt,  occasionally  occurs  before  the  first  menstruation 
appears,  but,  as  the  menstrual  flow  is  the  outward  sign  of  the  internal  sexual 
preparation,  the  period  of  sexual  activity  is  counted  as  beginning  with  the 
first  menstrual  flow. 

The  age  at  which  the  first  menstruation  appears  varies  in  different  races 
and  under  different  environment.  Climate  has  long  been  thought  to  influence 
the  beginning  of  menstruation — the  colder  the  climate  the  later  the  first 
menstruation.  This  holds  good  as  a  general  rule,  the  Laplander  beginning  to 
menstruate  at  about  18,  while  the  inhabitant  of  hot  climates  at  from  9  to  11. 
Engelmann  has  shown,  however,  that  in  some  of  the  most  northerly  tribes 
menstruation  appears  as  early  as  in  the  tropics.  The  mode  of  life  has  some 
influence,  as  has  also  the  general  health  of  the  girl.  Girls  reared  in  the  city 
begin  to  menstruate  earlier,  usually,  than  those  reared  in  the  country.  In 
addition  there  are  the  personal  inherited  tendencies,  about  which  we  know 
very  little,  but  which  exercise  a  marked  influence  on  the  phenomena  of  life. 

Occasionally  the  beginning  of  menstruation  is  long  delayed  without  any 
apparent  cause.  Hirst  had  a  patient  who  menstruated  for  the  first  time  at 
the  age  of  33,  had  four  periods  in  the  next  two  years,  and  then  conceived 
two  months  later.  He  records  also  a  reported  case  of  a  woman,  married  at 
34,  who  menstruated  for  the  first  time  at  the  age  of  45,  and  bore  a  child  at  46. 

In  the  United  States  a  girl  is  expected  to  begin  to  menstruate  when  she 
is  twelve  or  thirteen  or  fourteen.  Not  infrequently  the  menstrual  flow  begins 
at  the  age  of  ten  or  eleven,  and  hence  when  a  girl  reaches  about  the  age  of 
ten  her  mother  should  explain  to  her  that  a  slight  bloody  flow  may  be  ex- 


974  .  ■  DISTURBANCES    OF   FUNCTION 

pected  and  that  it  is  nothing  that  need  frighten  or  -worry  her,  but  entirely';' 
natural. 

The  period  of  puberty  is  sacred  to  the  physical  deA-elopment  of  the  girl. 
During  these  years  (i.  e.,  from  the  age  of  10  to  that  of  16)  she  should  live  in  a 
free  and  healthful  way — plenty  of  fresh  air  and  outdoor  exercise,  ■^rith  proper 
rest  at  menstrual  periods,  an  abundance  of  plain  nourishing  food,  regular 
hours  of  sleep,  only  a  moderate  amount  of  school  -work  and  other  mental  train- 
ing— in  short,  a  regimen  that  favors  free  physical  development,  unhampered 
by  exhausting  mental  Avork  or  by  indolent  habits.  Some  of  the  distressing 
disturbances,  pelvic  and  otherwise,  that  appear  later  in  life  are  due  to,  or 
increased  by,  neglect  at  this  developmental  period.  C4irls  are  permitted  to 
rise  late  and  sit  around  the  house,  doing  little  else  than  read,  vhen  they  should 
be  at  some  healthful  physical  work  (house-work,  outdoor  exercise,  etc.),  or, 
on  the  other  hand,  they  are  given  exhausting  school  studies,  immoderate  piano 
practice,  and  other  acquisitions  of  modern  life  that  keep  the  body  too  muc"!: 
indoors  and  in  one  posture,  and  that  develop  mental  activity  at  the  expense  qI 
physical  strength. 

2.  Ordinary  Menstruation.  The  phenomenon  is  known  under  a  variety  o^" 
names — for  example,  "menses,"  ''monthly  sickness,"  "monthly  period," 
"monthlies,"  "periods,"  "regular  sickness,"  "catamenia. "  Patients  usually 
refer  to  their  menstruation  as  the  time  when  they  were  "unwell." 

The  menstrual  flow  is  accompanied  by  certain  changes  in  the  endometrium. 
already  described  (page  584).  These  consist  principally  of  engorgement  and 
swelling  of  the  endometrium,  hemorrhagic  infiltration  and  the  casting  oif  of 
cell's  over  small  areas.  Cxebhard  has  demonstrated  conclusively  that  there  is 
no  wholesale  destruction  of  the  endometrium,  as  was  formerly  taught.  There 
are  also  some  changes  in  the  general  assimilative  and  excretory  processes  of  the 
body.  The  amount  of  urea  excreted  is  diminished,  the  apiDetite  is  poor,  and 
there  is  usually  more  or  less  aching  and  lassitude. 

The  menstrual  discharge  consists  of  blood  mixed  with  secretion  and  epi- 
thelium from  the  uterus  and  with  epithelium  from  the  vagina.  This  admix- 
ture with  mucus  and  epithelium  takes  place  to  such  an  extent  by  the  time 
the  vagina  is  reached  that  the  blood  does  not  clot.  It  is  dark  and  rather  viscid 
or  strmgy  from  its  admixture  with  cervical  mucus.  The  menstrual  discharge 
has  also  some  odor,  due  to  slight  decomposition,  which  takes  place  during  its 
passage  through  the  vagina.  Menstrual  blood  taken  directly  from  the  interior 
of  the  uterus  has  no  odor. 

The  amount  of  bloody  discharge  lost  at  each  menstruation  varies  greatly  in 
different  individuals,  the  usual  amount  being  from  five  to  ten  ounces.  The  rate 
of  flow;  i.  e.,  whether  or  not  the  flow  is  too  free — is  estimated  usually  by  the 
frequency  with  which  the  napkins  have  to  be  changed.  The  usual  flow  requires 
a  change  about  three  times  daily  during  the  height  of  the  menstruation.  If 
more  frequent  changing  is  necessary,  the  flow  is  too  free. 

There  is  considerable  variation  in  the  duration  of  the  menstrual  flow,  the 


NORMAL    MENSTRUATION  ■  975 

'.verage  being  three  to  four  days.  Some  perfectly  healthy  women,  however, 
.uenstruate  only  one  or  tAvo  days  arid  others  six  or  seven  days.  The  scanty 
nenstruation  or  the  i^rofuse  menstruation,  as  the  case  may  be,  seems  to  be 
normal  for  that  particular  individual.  The  duration  of  the  flow  in  the  same 
individual  is  usually  about  the  same  at  the  different  periods. 

The  periodicity  of  the  flow  is  more  uniform,  the  flowing  recurring  about 
every  28  days.  However,  many  healthy  women  menstruate  at  periods  some- 
what longer  or  shorter  than  this.  In  one  series  the  duration  from  beginning  to 
beguining  was  28  days  in  70  per  cent  of  the  cases,  30  days  in  13.7  per  cent,  27 
days  in  1.4  per  cent,  and  21  days  in  1.6  per  cent  (Krieger). 

Menstruation  ceases  during  pregnancy  and  lactation.  Exceptions  to  this 
rule  are  frequent.  A  few  women  menstruate  for  one  or  two  periods  after  con- 
ception, and  very  often  the  menses  return  while  a  woman  is  still  nursing  her 
child. 

The  principal  physiologic  significance  of  menstruation  is  that  it  is  a  prepa- 
ration of  the  uterus  for  the  reception  of  a  fertilized  ovum.  As  to  the  exact 
si<>'nificance  of  each  step  in  the  menstrual  pi*ocess,  and  as  to  whether  it  has  to  do 
with  other  important  functions  (eliminative),  there  is  still  much  dispute.  The 
f''d  conception  of  menstruation  as  a  general  cleansing  process  has  long  since 
disappeared,  but  recently  valuable  arguments  have  been  put  forth  to  show  that 
menstruation  is  the  direct  expression  of  ovarian  "internal  secretion."  (See 
Chapter  xv) . 

The  hygiene  of  the  menstrual  period  is  the  same  as  the  hygiene  of  any  other 
period,  except  that  there  should  be  a  little  less  phj^sical  and  mental  strain. 
Even  when  menstruation  is  perfectly  normal,  there  is  usually  some  feeling  of 
general  discomfort  and  a  disinclination  to  extra  physical  or  mental  exertion, 
and  this  feeling  should  be  favored  in  so  far  as  it  does  not  interfere  with  the 
general  healthful  routine  of  life.  Exercise,  tepid  bathing,  an  abundance  of 
sleep,  regular  meals  and  nourishing  food  are  all  as  necessary  at  this  time  as  at 
any  other. 

3.  Menopause.  In  a  healthy  woman  menstruation  ceases  at  the  age  of  44  to 
47.  There  is  considerable  variation  in  this  respect,  the  menses  sometimes  ceas- 
ing three  or  four  years  before  that  age  or  continuing  three  or  four  years  after- 
ward. It  is  very  exceptional,  however,  for  menstruation  to  cease  before  forty 
or  to  continue  after  fifty.  This  period  of  cessation  of  menstruation  is  known 
variously  as  the  "menopause,"  the  "climacteric,"  and  the  "change  of  life." 
The  changes  that  take  place  in  the  uterus  during  and  after  the  menopause  have 
already  been  described  (page  587).  They  are  similar  to  those  occurring  in  all 
the  genital  structures;  namelj^,  a  gradual  atrophy  of  the  functionating  part 
(endometrium  and  muscular  tissue),  a  general  fibrous  change  and  a  slow,  but 
decided,  diminution  in  size,  probably  the  result  of  ceasing  ovarian  secretion. 

The  menses  usually  cease  graduallj^ — that  is,  the  flow  may  be  less  free  or 
may  continue  a  shorter  time  than  usual,  or  the  flow  may  be  missed  entirely  for 
one  or  two  periods.     This  partial  and  irregular  absence  of  the  menstrual  flow 


976  DISTURBANCES   OF   FUNCTION 

may  continue  for  one  or  two  or  three  years  before  it  ceases  entirely.  This 
gradual  diminution  of  the  menstrual  flow  is  natural  and  there  are  frequently 
slight  nervous  disturbances  ("hot  flashes,"  etc.)  that  can  hardly  be  classed  as 
pathologic.  But  many  of  the  symptoms  that  are  ordinarily  considered  as  part 
of  the  ' '  change  of  life ' '  are  really  not  so ;  for  example,  increased  menstrual  flow, 
bloody  discharge  between  the  menstrual  periods,  leucorrhea,  pelvic  pain,  and 
marked  nervous  disturbances.  These  are  due  to  pathologic  conditions.  They 
mean  that  something  is  wrong,  and  they  require  investigation,  that  the  trouble 
may  be  remedied.  This  is  important  especially  in  the  case  of  vaginal  discharge, 
whether  bloody  or  leucorrheal.  It  seems  to  be  the  general  impression  among 
women  that  irregular  bloody  discharges  are  natural  during  the  "change  of  life." 
But  such  discharges  are  not  natural — they  usually  mean  either  inflammation  or 
cancer.  One  of  the  saddest  things  in  gynecologic  work  is  that  a  large  proportion 
of  the  cases  of  cancer  of  the  uterus  are  beyond  the  possibility  of  a  cure  when 
first  examined.  In  such  a  case  it  is  supposed  by  the  patient,  her  friends,  and 
all  too  often  by  physicians,  that  the  slight  bloody  discharge  which  at  first  appears 
is  "natural  to  the  change  of  life,"  and  so  no  attention  is  paid  to  it.  Later,  too 
late,  they  find  that  it  is  due  to  serious  disease,  which,  because  of  neglect,  has 
progressed  to  such  an  extent  that  it  is  beyond  cure. 

ABSENCE  OF  MENSTRUATION  (AMENORRHEA) 

A  general  theoretical  consideration  of  the  problem  of  amenorrhea  will  be 
found  in  Chapter  xv,  and  the  discussion  here  wdll  be  limited  to  the  practical 
aspects  of  the  condition. 

Amenorrhea  is  the  absence  of  menstruation  for  one  or  more  periods  between 
puberty  and  the  menopause.  This  definition  includes  the  absence  of  the  menses 
during  pregnancy  and  lactation.     This  is  known  as  "physiologic  amenorrhea." 

Pregnancy  must  always  be  taken  into  consideration  in  a  case  of  amenorrhea, 
and  before  the  amenorrhea  is  attributed  to  any  other  cause  pregnancy  must  be 
excluded — ^by  the  circumstances  of  the  case  or  by  questioning  the  patient  or  by 
an  examination. 

Amenorrhea  from  other  causes  is  found  principally  in  girls  and  young 
women  in  whom  the  function  of  menstruation  has  not  yet  been  completely  estab- 
lished. The  age  of  puberty ;  i.  e.,  the  beginning  of  menstruation — varies  within 
normal  limits  considerably.  Girls  begin  to  menstruate,  as  a  rule,  at  the  age  of 
12  or  13  or  14.  The  beginning  of  menstruation  may  be  postponed  until  the  age 
of  16  or  17  without  disturbance.  Usually,  however,  after  the  age  of  16,  and  often 
before  that,  if  the  menstrual  flow  does  not  appear,  there  are  disturbances  that 
indicate  some  departure  from  normal  health,  and  the  patient  may  be  said  to 
have  amenorrhea. 

Amenorrhea  is  not  a  disease,  but  only  a  symptom.  It  may  be  an  indication 
of  any  one  of  several  entirely  distinct  conditions,  just  as  a  cough  may  be  an 
indication  of  laryngitis  or  bronchitis,  or  pneumonia  or  tuberculosis.    When  a 


AMENORRHEA  977 

patient  comes  complaining  that  she  does  not  menstruate,  the  first  thing  to  do  is 
to  determine  why  she  does  not  menstruate ;  i.  e.,  what  disease  or  condition  lies 
back  of  this  symptom. 

In  practice  it  is  convenient,  for  purposes  of  diagnosis  and  treatment,  to 
divide  the  cases  of  amenorrhea  into  two  classes — one  class  including  those  patients 
who  have  never  menstruated  and  the  other  class  including  those  who  have. 

(A)  WHEN  THE  PATIENT  HAS  NEVER  MENSTRUATED 

A  mother  brings  her  daughter,  aged  15  or  16  or  perhaps  18,  to  you,  stating 
that  the  girl  has  never  come  unwell.  The  mother  is  anxious  to  know  why  the 
girl  does  not  come  unwell  and,  of  course,  what  should  be  done  for  her. 

Causes 

In  such  a  case  the  absence  of  menstruation  may  be  due  to  one  of  three 
causes,  as  follows: 

1.  Poor  general  health,  with  pronounced  anemia. 

2.  Some  obstruction  in  the  genital  canal. 

3.  Imperfect  development  of  the  uterus. 

Which  of  the  causes  is  present  in  this  particular  patient?  That  you  must 
find  out  by  investigation,  and  the  first  step  in  that  investigation  is  to  deter- 
mine the  state  of  the  patient's  general  health.  Is  she  pale,  weak,  lacking  in 
vigor,  always  tired,  easily  exhausted  by  light  work?  If  so,  the  amenorrhea  is 
probably  due  to  the  first  cause  mentioned. 

1.  Poor  General  Health,  with  Pronounced  Anemia.  The  next  step  is  to 
search  carefully  for  the  cause  of  the  poor  vitality,  with  its  resulting  anemia. 
The  mother  usually  thinks  the  poor  health  is  due  to  the  absence  of  the  menses, 
while  the  fact  is  that  the  absence  of  the  menses  is  due  to  the  poor  health,  and 
the  poor  health  is  due  to  some  general  or  local  disease,  the  nature  of  which  it 
is  your  province  to  ascertain. 

Now,  it  would  be  out  of  place  here  to  attempt  to  take  up  in  detail  the  differ- 
ential diagnosis  of  all  the  diseases  which  may  cause  deterioration  of  the  general 
health,  with  marked  anemia  and  amenorrhea.    Some  of  the  common  causes  are : 

a.  Tuberculosis  is  a  Very  frequent  cause  of  amenorrhea.  It  may  appear  in 
the  form  of  tuberculosis  of  the  lungs,  or  of  the  intestines  or  of  the  peritoneum, 
or  of  the  glands  or  of  the  bones,  or  of  the  urinar^^  organs — any  of  the  various 
forms  of  tuberculosis.  The  proper  questions  must  be  asked  to  elicit  the  informa- 
tion necessary  to  establish  the  presence  or  absence  of  this  disease. 

b.  Malaria,  particularly  in  the  chronic  form,  is  a  frequent  cause  of  anemia 
in  malarial  regions. 

c.  Acute  disease,  such  as  typhoid  fever,  pneumonia,  diphtheria,  and  the 
exanthemata  occurring  at  puberty,  may  weaken  the  patient  so  much  as  to  delay 
the  beginning  of  menstruation  for  many  months. 


978  DISTURBANCES    OF   FUNCTION 

d.  Heart  disease  following  rheumatism  in  childhood  may  cause  persistent 
and  severe  disturbances  of  nutrition. 

e.  Digestive  disturbances  or  kidney  lesion,  or  diseases  of  the  nervous  system, 
may  cause  a  depression  of  vitality  to  such  an  extent  that  the  patient  does  not 
menstruate. 

f.  Confinement  indoors,  exhausting  studies,  overwork,  poor  food,  lack  of 
exercise — any  of  these  things  may  cause  anemia  with  amenorrhea. 

g.  Chlorosis.  In  some  cases  we  can  find  no  definite  local  or  general  disease 
to  account  for  the  blood  condition — -the  pronounced  anemia.  In  this  class  come 
the  cases  of  chlorosis,  and  of  pernicious  anemia  and  of  the  other  so-called  ' '  pri- 
mary" anemias.  The  differential  diagnosis  of  these  forms  of  anemia  belongs  to 
general  medicine,  and  the  diagnostic  points  are  described  under  diseases  of  the 
blood.  Chlorosis  occurs  so  frequently  in  girls  and  young  women  that  it  is  some- 
times classed  as  a  gynecologic  affection,  but  it  belongs  to  general  medicine  the 
same  as  the  other  blood  diseases. 

h.  Some  of  the  diseases  due  to  functional  disturbances  in  one  or  more  of  the 
endocrin  glands,  such  as  diabetes  (pancreas)  exophthalmic  goiter  or  myxedema 
(thyroid),  tetany  (parathyroids),  acromegaly  (hypophysis),  etc.,  quite  commonly 
are  associated  with  amenorrhea  (see  Chapter  xv). 

Suppose,  however,  that  our  patient  is  not  anemic,  but  is  rosy,  robust  and 
apparently  in  good  general  health.    What  then  causes  the  amenorrhea? 

2.  It  may  be  due  to  some  obstruction  in  the  g-enital  canal.  The  obstruction 
is  due  to  some  malformation,  such  as  imperforate  hymen,  or  atresia  of  vagina  or 
atresia  of  cervix  uteri.  These  malformations  are  rare,  the  most  frequent  being 
imperforate  hymen  (page  966). 

Obstruction  in  the  genital  canal  gives  rise  to  no  symptoms  until  puberty  is 
reached.  At  the  age  of  13  or  14  or  later  the  patient  begins  to  feel  very  bad  each 
month.  At  intervals  of  about  four  weeks  she  notices  marked  lassitude  and  loss 
of  appetite,  feels  somewhat  feverish  and  out  of  sorts,  has  pain  in  various  parts 
of  the  body,  more  particularly  in  the  back  and  lower  abdomen.  She  complains 
just  as  a  woman  does  when  she  is  about  to  be  unwell.  Her  mother  thinks  she  is 
coming  unwell  but  no  fiow  appears.  After  a  few  days  the  pain  and  other  disturb- 
ing symptoms  subside  and  she  feels  fairly  well  until  the  next  month. 

After  several  months  the  pain  and  accompanying  disturbances  last  longer — 
in  fact,  may  become  almost  continuous — and  the  patient's  general  health  begins 
to  suffer.    A  swelling  may  appear  in  the  lower  abdomen  or  at  the  vaginal  entrance. 

Such  a  history  makes  a  local  examination  imperative.  In  the  local  exami- 
nation, if  the  condition  be  imperforate  hymen,  the  vaginal  entrance  is  found 
closed.  There  may  be  a  bulging  of  the  hymen  due  to  the  pressure  of  menstrual 
blood  behind  it.  If  the  atresia  is  situated  high  in  the  vagina,  the  vaginal  en- 
trance is  found  open,  but  after  the  examining  finger  has  been  introduced  for  a 
short  distance  it  meets  an  obstruction,  consisting  of  a  wall  of  tissue  blocking  the 
vagina.  If  there  is  a  collection  of  menstrual  blood  behind  the  obstruction  fluc- 
tuation may  be  obtained.    Digital  examination  by  the  rectum  will  give  additional 


AMENORRHEA  979 

information  as  to  the  location  and  length  of  the  vaginal  atresia  and  as  to  the 
amount  of  menstrual  fluid  collected  behind  it.  In  long-standing  cases  the  vagina 
and  uterus  and  even  the  Fallopian  tubes  may  be  distended  with  blood. 

In  cases  of  atresia  of  the  vagina  there  are  very  liable  to  be  other  malforma- 
tions higher,  and  sometimes  the  uterus  is  entirely  absent.  If  the  patient  is  past 
the  age  of  puberty  and  no  collection  of  blood  is  found  above  the  vaginal  atresia, 
the  strong  probability  is  that  the  uterus  and  appendages  are  either  absent  or  so 
poorly  developed  that  menstruation  would  be  impossible  even  though  the  vaginal 
obstruction  were  removed.  Careful  examination  should  be  made  to  determine 
certainly  whether  or  not  the  uterus  is  present. 

But  suppose  the  girl  is  healthy — good  color,  good  general  health,  and  no 
local  malformation — what  then  causes  the  amenorrhea  ? 

3.  It  may  be  due  to  imperfect  development  of  the  uterus.  This  poor  devel- 
opment of  the  uterus  may  be  simply  part  of  a  general  under-development,  or  it 
may  be  limited  to  the  uterus  and  appendages,  the  patient  being  otherwise 
strong  and  fully  developed. 

In  some  cases  the  imperfect  development  is  so  marked  that  it  can  be  proved 
by  examination  (body  of  uterus  very  small).  In  other  cases  the  imperfection 
is  less  marked — the  uterus  and  appendages  are  apparently  normal,  as  far  as 
can  be  determined  by  ordinary  bimanual  palpation,  and  still  the  development 
has  stopped  short  of  perfection,  as  is  shown  by  the  fact  that  the  patient  does  not 
menstruate  and  that  treatment  directed  toward  stimulating  development  brings 
on  the  menstrual  flow. 

Treatment 

The  patients  now  under  consideration  are  girls  and  young  women  who  have 
never  menstruated.  If  there  are  no  marked  local  symptoms  pointing  to  obstruc- 
tion, the  flrst  step  in  treatment  is  to  put  the  patient  in  the  best  possible  general 
health.  A  local  examination  is  not  indicated  at  first  in  the  absence  of  local 
symptoms.  The  anemia  should  be  corrected,  and  the  general  health  improved 
and  the  normal  function  stimulated  by  the  following  measures : 

1.  The  long  continued  administration  of  iron,  accompanied  by  arsenic  or 
stryehina  or  other  tonics,  as  indicated  by  the  conditions  present. 

2.  Curtail  Exhausting-  School  Duties,  immoderate  piano  practice  and  other 
acquisitions  of  modern  life  that  keep  the  body  too  much  indoors  and  in  one 
posture,  and  that  develop  mental  activity  at  the  expense  of  physical  strength. 

The  mind  should  be  trained,  of  course,  but  it  should  be  trained  in  a  way 
that  does  not  interfere  with  the  development  of  the  body.  The  age  of  puberty 
is  sacred  to  the  physical  development  of  the  girl  and  nothing  should  be  allowed 
to  interfere  with  it.    ' 

A  step  in  the  right  direction  is  the  introduction  of  regular  gymnastic  exer- 
cises in  the  curriculum  of  the  public  schools.  This  needs  to  be  extended  and 
combined  with  a  certain  amount  of  outdoor  exercises. 


980  DISTURBANCES    OF   FUNCTION 

The  course  of  study  iu  the  public  schools  should  be  under  such  medical 
supervision  that  the  pupils  be  not  unduly  taxed,  and  when  it  is  seen  that  a  girl 
is  not  doing  well  physically,  her  parents  should  be  advised  to  take  her  out  for  a 
time  and  let  her  live  the  outdoor  life  that  she  needs.  Such  a  step  in  time  would 
turn  many  a  girl  from  the  path  of  imperfect  development  and  lifelong  invalidism, 
and  cause  her  to  become  a  healthy,  robust  and  useful  woman — an  ornament  to 
society  and  a  blessing  to  all  around  her. 

3.  Regular  and  Moderate  Exercise.  There  are  excellent  general  works  on 
the  various  forms  of  exercise,  and  a  careful  study  of  this  subject  is  advisable, 
for,  in  many  affections,  well-directed  exercise  is  one  of  our  best  remedies.  The 
orders  to  the  patient  will  be  about  as  follows: 

a.  Take  five  to  ten  minutes'  exercise  with  a  AVhitely  exerciser,  or  other 
good  exerciser,  each  night  after  the  clothing  is  loosened  for  retiring.  The  ex- 
ercise should  be  taken  regularly — every  night  without  fail.  It  should  be  mod- 
erate at  first,  not  more  than  five  minutes,  and  the  time  lengthened  as  the  patient 
becomes  used  to  it.  It  should  not  be  violent.  Begin  with  correct  standing  and 
walking  and  then  pass  to  the  arm  movements  and  the  movements  that  involve  the 
chest  muscles,  the  expansion  of  the  chest,  etc.  As  the  patient  gets  used  to  the 
work  and  can  extend  the  time,  other  movements  may  be  taken  up,  movements 
involving  the  abdominal  and  back  muscles  and  the  muscles  of  the  hips  and  lower 
extremities.  It  is  a  good  plan,  however,  to  always  take  the  arm  movements,- 
either  at  the  beginning  or  end  of  each  exercise  period. 

b.  Take  a  walk  of  5  to  10  blocks  (i^  to  %  mile)  each  day.  It  is  best  to  have 
a  regular  time  for  this.  This  exercise  should  be  regular  and  moderate,  and  deep 
breathing  should  be  remembered  (a  deep  breath  every  8  to  10  inspirations)  and 
correct  easy  position  in  standing  and  walking. 

With  this  as  with  the  indoor  gymnastic  exercise,  it  is  not  the  length  or 
amount  of  exercise  so  much  as  the  regularity  of  it  that  accomplishes  the  desired 
result. 

c.  Other  forms  of  outdoor  activity,  such  as  horseback  riding,  driving,  row- 
ing and  the  various  outdoor  sports  are  excellent,  as  they  keep  the  patient  out  in 
the  open  air  and  sunshine  and  at  the  same  time  necessitate  considerable  muscular 
activity.  They  are  particularly  invigorating  because  they  add  to  the  necessary 
exercise  a  healthful  interest  and  anticipation  and  enjoyment.  But  these  things 
should  not  be  allowed  to  interfere  with  the  regular  walk  and  gymnastic  exercise 
— in  fact,  at  the  first  regular  g^nnnastic  exercise  and  walk  will  probably  be  all  the 
patient  can  take  without  fatigue,  and  it  is  only  after  these  have  been  practiced 
for  a  time  that  the  more  active  out-of-door  sports  can  be  undertaken  without 
harmful  fatigue.  These  latter  are  to  be  taken  only  in  addition  to  the  other  when 
the  patient  is  ready,  and  not  in  place  of  them. 

4.  Reg-ular  Meals  and  Suitable  Food.  An  abundance  of  good  nourishing 
food  should  be  taken  at  regular  intervals.  At  first  the  patient's  appetite  will 
probably  be  capricious  and  she  will  not  care  for  much  substantial  food.     Do 


AMENORRHEA  981 

not  try  to  stuff  her  and  do  not  tell  her  she  must  eat  a  gre^t  deal  of  this  or 
that  article  of  food,  of  which  even  the  thought  perhaps  destroys  what  little 
appetite  she  has.  Rather  give  the  exercise  that  Avill  after  a  time  give  her  an 
appetite,  and,  after  she  gets  so  she  is  really  hungry,  tell  her  what  article  of  diet 
she  can  not  have,  leaving  her  to  find  her  food  from  the  other  articles  or  go 
hungry.  Thus  by  giving  her  an  appetite  and  cutting  off  the  umvholesome 
articles  with  which  she  has  perhaps  been  accustomed  to  pamper  herself,  she 
will  soon  be  taking  an  abundance  of  good  substantial  food  and  be  glad  to  get 
it.  The  result  will  be  good  blood,  strong  muscles,  sound  sleep,  graceful  car- 
riage, healthy  color,  clear  mind,  sweet  temper  and  a  general  attractiveness 
which  can  never  be  supplied  by  cosmetics  and  indolent  luxury. 

5.  After  the  patient  is  well  started  on  this  regimen,  say  after  one  or  two 
months,  she  may  be  given  some  of  the  emmenag'ogTie  preparations,  provided 
the  menstruation  has  not  already  begun.  In  some  cases  as  soon  as  the  patient 
is  put  in  good  general  health  the  menstruation  begins  normally.  In  other 
cases  the  menstruaton  does  not  appear,  even  when  the  patient  has  been  re- 
stored to  apparently  good  general  health. 

In  such  a  case  the  tonic  regimen  is  continued  and  in  addition  some  em- 
menagogue  preparation  is  given,  such  as  a  manganese  dioxide,  or  some  of  the 
iron  preparations.  Ovarian  extract  in  some  instances  yields  satisfactory 
results. 

If  after  two  or  three  months  of  this  treatment  the  menstrual  flow  does 
not  appear,  or  at  any  time  if  marked  local  symptoms  develop,  make  a  vaginal 
and  bimanual  examination  and  determine  if  there  is  any  obstruction  to  the 
flow  or  any  other  pathologic  lesion  needing  correction. 

If  an  obstruction  (imperforate  hymen  or  atresia  of  vagina)  is  found,  it 
must  be  treated  as  described  elsewhere  under  the  organic  lesion. 

If  no  obstruction  is  found  and  the  organs  are  apparently  normal,  it  is  then 
to  be  assumed  that  the  trouble  is  due  to  imperfect  development  of  the  uterus — 
that  is,  that  the  organ  has  stopped  short  of  perfection.  We  then  employ 
measures  to  stimulate  the  uterus  or  the  ovary  respectively  to  functional 
activity. 

The  tonics,  the  exercise,  the  emmenagogues  and  the  other  measures  men- 
tioned tend  in  that  direction.  One  of  the  local  measures  frequently  used  for 
stimulating  a  poorly  developed  uterus  is  electricity  in  its  various  forms,  both 
galvanic  and  f aradic. 

If  the  symptoms  recur  at  regular  intervals,  indicating  that  this  is  the  time 
when  the  menstrual  flow  is  nearly  ready  to  start,  use  hot  sitz-baths,  hot  foot 
baths,  and  warm  applications  to  the  lower  abdomen. 

The  propriety  of  intravaginal  measures  depends  somewhat  on  the  patient. 
In  some  patients  the  vaginal  opening  is  large  and  the  patient  is  not  particularly 
nervous,  and  local  treatment  may  be  carried  out  without  special  trouble.  In 
such  a  case  applications  of  silver  nitrate  solution  (4%  to  10%)  to  the  cervix 


982  DISTURBANCES   OF   FUNCTION 

may  be  made  every  other  day  at  the  time  when  the  precursory  symptoms  of 
menstruation  appear.  The  hot  douche  also  may  be  used  two  or  three  times 
daily.  If  these  are  still  ineffective,  vagino-abdominal  applications  of  electricity 
may  be  tried. 

In  the  case  of  a  patient  who  is  nervous  and  distressed  by  the  local  treat- 
ment, and  particularly  if  the  vaginal  opening  is  very  small,  no  intravaginal 
treatment  should  be  employed  without  anesthesia,  except  the  introduction  of 
the  small  vaginal  electrode  or  the  giving  of  hot  vaginal  douches.  In  such  a 
case  no  intrauterine  treatment  is  used  unless  there  is  some  indication  for  giving 
the  patient  an  anesthetic. 

It  may  be  that  an  anesthetic  is  required  to  make  a  careful  examination  to 
determine  whether  or  not  there  is  any  serious  abnormality  of  the  organs.  In 
such  a  case  it  is  well  to  have  instruments  ready  for  dilating  the  cervix,  as  that 
seems  to  act  as  a  stimulant  to  menstruation  in  these  cases.  In  some  eases  curet- 
ment  is  indicated  as  a  local  stimulant. 

Occasionally  there  is  anteflexion  with  atrophic  endometritis,  and,  if  that 
condition  be  present,  the  uterus  had  best  be  curetted  at  the  same  time  that 
the  cervix  is  dilated.  During  this  treatment  under  anaesthesia  the  vaginal 
entrance  and  cervix  uteri  should  be  well  dilated,  so  that  an  intrauterine  elec- 
trode may  be  used  later,  if  necessary. 

In  a  case  of  amenorrhea  where  the  girl  is  engaged  to  be  married,  the  ques- 
tion of  the  propriety  of  marriage  sometimes  comes  up — the  parents  or  the 
patient  desiring  to  know  whether  it  would  be  right  for  her  to  marry  when  she 
has  never  menstruated.  The  answer  is,  that  if  there  is  no  organic  lesion,  which 
in  itself  is  a  bar  to  marriage,  marriage  is  perfectly  proper,  just  the  same  as 
though  the  girl  were  menstruating  regularly.  In  such  a  case  the  absence  of 
menstruation  is  simply  a  functional  disturbance,  which  will  probably  soon 
disappear  under  the  influence  of  a  happy  married  life. 

(B)   WHEN  THE  PATIENT  HAS  MENSTRUATED 

When  the  patient  has  menstruated  one  or  more  times,  the  absence  of  men- 
struation is  due  to  one  of  the  following  causes: 

1.  Some  condition  connected  with  pregnancy. 

2.  Some  other  forms  of  physiologic  amenorrhea. 

3.  Poor  general  health,  with  anemia. 

4.  Acute  general  disease. 
.5.  Local  (pelvic)  disease. 

6.  Operative  removal  of  essential  structures. 

7.  Obesity. 

8.  Nervous  impressions. 

9.  Suppression  of  menses. 

1.  Pregnancy.  A.  Normal  Pregnancy.  If  the  patient  has  previously  been 
regular  in  menstruation,  is  in  good  health  and  has  had  an  opportunity  to  be- 


AMENORRHEA  -  983 

come  pregnant,  the  natural  supposition  is  that  she  is  pregnant,  and  until  it  is 
proved  that  she  is  not  pregnant,  nothing  should  be  done  that  could  in  any  way 
interfere  with  pregnancy. 

The  patient  may  assert  positively  that  she  is  not  pregnant,  may  even  deny 
any  possibility  of  pregnancy,  but  when  after  examination  there  is  any  sus- 
picion in  your  mind,  postpone  all  local  treatment  until  after  the  next  menstrual 
flow.  If  you  doubt  the  patient's  honesty,  that  is,  if  you  think  she  may  return 
and  tell  you  that  she  menstruated  when  in  fact  she  did  not — tell  her  that  she 
must  come  during  the  flow,  that  you  may  determine  the  character  of  the  flow. 
In  this  way  you  can  establish  certainly  whether  or  not  she  really  menstruates. 

In  this  matter  of  the  question  of  pregnancy  it  requires  considerable  judg- 
ment and  tact,  on  the  one  hand,  to  detect  the  cases  of  pregnancy,  and,  on  the 
other  hand,  to  avoid  wounding  the  feelings  of  innocent  persons  by  ill-advised 
questions.  Concerning  the  question  of  pregnancy,  the  cases  may  be  divided  into 
three  classes.  In  the  first  class  come  the  girls  and  unmarried  women  in  which, 
from  the  character  of  the  trouble  or  from  the  known  character  of  the  patient, 
the  possibility  of  pregnancy  may  be  at  once  eliminated.  These  correspond  very 
closely  with  the  patients  who  have  never  menstruated  and  require  the  same 
treatment. 

In  the  second  class  come  the  married  women.  In  these  an  examination  may 
be  made  at  once  and  the  diagnosis  of  pregnancy  settled  thus.  If  the  diagnosis 
is  still  doubtful  after  examination,  the  patient  is  told  that  it  is  too  early  yet 
to  be  certain  about  it  and  she  is  directed  to  come  again  after  a  month  or  six 
weeks. 

In  the  third  class  come  the  girls  and  unmarried  women  about  whom  you 
know  but  little — they  may  be  all  right  or  they  may  be  all  wrong;  you  simply 
do  not  know  and  hence  must  be  cautious.  In  this  class  come  also  widows, 
■divorced  persons,  women  living  apart  from  their  husbands — all  of  whom,  if 
pregnant,  might  wish  to  conceal  the  fact.  Some  of  these  patients  are  perfectly 
truthful  with  the  physician,  telling  him  their  fears  or  leaving  a  clear  opening 
for  the  asking  of  questions  that  would  bring  out  the  information.  In  other 
cases  the  patient  gives  the  whole  history  of  her  case  without  any  intimation  of 
a  misstep.  Occasionally  the  patient  tries  deliberately  to  deceive  the  physician, 
hoping  that  in  his  examination  or  treatment  something  may  be  done  that  will 
bring  about  an  abortion. 

In  such  uncertain  cases  it  is  usually  best  for  the  physician  to  keep  his 
thoughts  to  himself,  and  not  to  intimate  any  suspicion  of  pregnancy  until  some 
good  evidence  of  it  is  found.  Do  not  depend  too  much  upon  the  history  the 
patient  gives.  Just  keep  in  mind  that  it  may  be  all  truth  and  it  may  be  all 
^falsehood.  If  the  patient  is  a  girl  or  unmarried  woman,  an  examination  need 
not  be  made  at  once.  She  may  be  placed  on  tonic  treatment  that  will  not 
interfere  with  pregnancy.  This  will  put  her  in  better  condition  for  menstru- 
ation and  in  the  meantime  the  case  may  be  observed  and  developments  watched 


984  '  DISTURBANCES   OF   FUNCTION 

for.  If  after  several  weeks  menstruation  does  not  appear,  an  examination  may 
be  suggested.  If  the  patient  was  formerly  married,  or  lias  taken  local  treat- 
ment or  has  had  an  examination  made,  an  examination  may  be  advisable  at 
once.  If  the  examination  signs  are  not  decisive  either  way,  the  patient  may 
be  kept  on  tonic  treatment  and  another  examination  made  after  several  weeks. 

In  this  way  the  physician  protects  himself  and  at  the  same  time  gives  the 
patient  good  treatment.  If  it  turns  out  that  no  pregnancy  is  present,  the 
patient  need  never  know  that  pregnancy  was  suspected.  On  the  other  hand, 
if  it  turns  out  that  pregnancy  is  present,  nothing  has  been  done  that  could 
possibly  interfere  with  it.  He  has  done  what  was  right  for  the  patient  and 
has  protected  himself,  and  accordingly  prevented  the  patient  from  making  a 
fool  of  him,  as  some  of  the  deluded  ''smart"  ones  try  to  do. 

B.  Extrauterine  Pregnancy.  The  evidences  of  tubal  pregnancy  have  al- 
ready been  given  (page  884). 

2.  Other  Forms  of  Physiologic  Amenorrhea.  A.  Lactation.  As  a  rule,  a 
woman  does  not  menstruate  while  nursing  a  baby.  There  are,  however,  many 
exceptions  to  this  rule,  especially  after  the  first  six  months.  Quite  frequently 
a  patient,  while  nursing  her  child,  will  begin  to  menstruate  within  five  or  six 
months  after  labor  and  occasionally  within  two  or  three  months.  This  happens 
most  frequently  in  those  cases  in  which  the  mother  has  only  enough  milk  to 
partly  nourish  the  baby. 

B.  Beginning  Menopause.  The  age  at  which  the  menopause  begins  varies 
much  in  different  persons.  The  average  age  is  about  forty-five,  but  it  often 
begins  somewhat  earlier,  in  exceptional  cases  before  forty.  If  the  patient  is 
past  forty  and  the  menstrual  flow  has  been  getting  gradually  less  for  several 
months,  the  menopause  is  probably  beginning.  There  are  two  separate  phenom- 
ena that  usually  accompany  the  climacteric  and  that  may  aid  in  the  diagnosis 
— the  ''hot  flashes"  with  some  irritability  and  other  evidences  of  nervousness, 
and  the  tendency  to  increase  in  the  subcutaneous  fat  deposit.  Neither  one  of 
these  is  pathognomonic,  but  both  of  them  occurring  in  a  patient  past  forty, 
with  menstruation  gradually  diminishing,  make  the  diagnosis  of  the  climacteric 
fairly  certain. 

3.  Poor  Health,  with  Pronounced  Anemia.  There  is  poor  blood,  poor  gen- 
eral health  and  want  of  tone,  secondary  to  some  wasting  disease  or  to  chlorosis. 
The  cause  is  determined  by  a  careful  general  examination  of  the  patient,  in- 
cluding, Avhen  necessary,  examination  of  the  urine  and  of  the  sputum  and  of  the 
blood.  It  is  usually  due  to  some  chronic  disease.  It  may  come  from  any  of 
the  conditions  mentioned  under  anemia  in  patients  who  have  never  menstru- 
ated (page  977)  or  from  other  troubles  that  reduce  the  patient's  vitality. 
Among  the  latter  may  be  mentioned  prolonged  lactation,  pregnancies  too  close 
together,  close  confinement  indoors  with  housework  or  children,  and  sameness 
of  work  day  after  day  without  stimulating  varietj^ 

4.  Acute  Disease.  Acute  diseases,  such  as  typhoid  fever,  pneumonia,  the 
exanthemata,  influenza  or  even  a  severe  cold,  may  delay  menstruation  or  cause 


AMENORRHEA  "  983 

it  to  be  missed  entirely,  particularly  if  the  attack  comes  about  the  menstrual 
time.  On  the  other  hand,  the  beginning  of  an  acute  disease  may  cause  the 
menstrual  flow  to  appear  too  soon  or  to  be  too  free. 

5.  Local  (Pelvic)  Disease.  The  local  diseases  that  may  cause  amenorrhea, 
independent  of  their  general  effect  on  the  blood,  are  those  diseases  that  affect 
the  integrity  of  the  endometrium  (from  which  comes  the  menstrual  blood)  or 
that  affect  the  integrity  of  the  ovaries  (from  which  comes  the  menstrual 
impulse). 

A.  Hyperinvolution  of  Uterus.  The  process  of  involution  following  preg- 
nancy and  labor  may  continue  farther  than  normal,  reducing  the  uterus  below 
normal  size  and  so  modifying  the  endometrium  as  to  interfere  with  menstru- 
ation. This  is  a  rare  condition,  but  must  be  kept  in  mind  in  considering  a  case 
of  amenorrhea  in  a  patient  who  has  given  birth  to  a  child  within  a  year  or  two. 
In  one  of  the  author's  cases  the  patient  was  28  years  of  age.  Three  years 
jjefore  she  had  had  a  severe  infection  following  the  birth  of  her  child  and  there 
had  been  no  menstruation  since.  Bimanual  examination  showed  the  uterus 
to  be  very  small.  On  account  of  other  trouble  it  was  necessary  to  open  the 
abdomen,  and  the  opportunity  of  inspecting  the  internal  genital  organs  was 
offered.  Everything  was  atrophic — the  uterus,  ovaries,  tubes  and  round  liga- 
ments. The  uterus  was  about  half  the  normal  size.  Hyperinvolution  may 
occur  also  following  simple  curetment  for  chronic  endometritis,  though  that  is 
even  more  rare. 

B.  Cirrhosis  of  the  Uterus.  This  is  the  last  stage  of  chronic  metritis,  that 
stage  in  which  the  wall  of  the  uterus  and  the  endometrium  are  largely  con- 
verted into  scar-tissue.  There  is  loss  of  the  functionating  elements,  marked 
diminution  of  the  blood  supply  and  consequent  cessation  of  function  before 
the  appointed  age. 

C.  Destruction  of  Ovaries  l)y  Disease.  The  ovaries  furnish  the  menstrual 
impulse,  and  when  they  are  so  damaged  by  disease  that  all  of  the  functionating 
elements  (Graafian  follicles  with  contained  ova)  are  destroyed,  and  no  corpus 
luteum  is  formed,  menstruation  ceases.  This  rarely  happens,  for  even  in  ex- 
tensive and  destructive  pelvic  inflammation,  enough  of  one  ovary  usually 
survives  to  continue  menstruation,  providing  the  patient's  general  health  is 
not  too  much  affected. 

6.  Operative  Removal  of  Structures.  The  structures  essential  to  continu- 
ous regular  menstruation  are  the  uterus  and  some  functionating  ovarian  tissue. 

A.  Hysterectomy.  The  removal  of  the  uterus  ordinarily  means  cessation 
of  menstruation.  In  certain  cases  of  supravaginal  hysterectomy  for  fibroids,  suf- 
ficent  of  the  lower  part  of  the  corpus  uteri  may  be  preserved  to  continue  men- 
struation (Chapter  xiv).  Of  course,  such  an  operation  constitutes  only  a  par- 
tial amputation  of  the  corpus  uteri.  The  removal  of  the  cervix  uteri  alone  has 
practically  no  effect  on  menstruation. 

B.  Doiihle  Oophorectomy.     The  complete  removal  of  both  ovaries  (removal 


986  DISTURBANCES   OF   FUNCTION 

of  all  ovarian  tissue  iii  the  pelvis)  causes  menstruation  to  cease,  either  at  once 
or  within  a  short  time.  In  many  cases,  even  with  both  ovaries  badly  damaged, 
enough  ovarian  tissue  may  be  left  to  continue  menstruation.  In  suitable  cases 
this  is  the  practice  ordinarily  followed.  To  secure  the  desired  result,  how- 
ever, the  ovarian  tissue  left  must  continue  to  functionate. 

On  the  other  hand,  in  exceptional  cases,  when  both  ovaries  have  supposedly 
been  completely  removed,  the  patient  has  continued  to  menstruate  and  has  even 
become  pregnant.  That  means,  of  course,  that  some  ovarian  tissue  was  left. 
Some  part  of  the  normal-shaped  ovaries  may  have  been  unwittingly  left  or  there 
may  have  been  lobulation  of  one  ovary.  Islands  of  ovarian  tissue,  from  mal- 
formation of  ovary,  are  occasionally  found  in  the  pelvis,  either  close  to  the 
normal  site  of  the  ovary  or  at  some  distant  part  of  the  broad  ligament  (page  965) . 

The  removal  of  one  ovary  has  little  or  no  effect  on  menstruation,  provided 
the  other  continues  to  functionate.  The  removal  of  one  or  both  Fallopian  tubes 
has  no  effect  on  menstruation. 

7.  Obesity.  The  condition  of  the  system  associated  with  the  excessive 
deposit  of  fat  very  frequently  causes  diminution  in  the  menstrual  flow  and 
may  cause  it  to  cease  altogether  for  a  time.  This  may  occur  with  obesity  in 
girls  as  well  as  in  older  women.     (See  Chapter  xv) . 

8.  Nervous  Impressions.  Nervous  impressions  may  delay  or  stop  the 
menses  for  a  few  months,  or  delay  their  appearance  if  occurring  at  puberty. 
Among  these  may  be  mentioned:  a  long  journey  (particularly  on  shipboard), 
change  of  residence  from  country  to  city  or  vice  versa,  extraordinary  grief,  joy,  or 
anxiety,  or  exciting  work,  study  (as  in  preparing  for  examination),  taking  up  a 
new  occupation,  financial  troubles,  love  affairs  and  difficulties  in  home  life.  Any 
of  these  may  cause  an  expected  menstruation  to  be  missed. 

Treatment 

The  treatment  required  is  indicated  by  the  particular  abnormal  condition 
present.  The  methods  of  treatment  for  the  various  organic  diseases  are  given 
in  the  appropriate  chapters. 

In  anemia  employ  the  course  of  tonic  treatment  followed  by  emmenagogues, 
previously  described  for  anemia  in  patients  who  have  never  menstruated. 

In  married  women,  with  no  decided  organic  lesion,  the  poor  general  health 
may  be  due  to  prolonged  lactation,  to  pregnancies  coming  too  close  together,  to 
the  worry  and  care  of  children,  with,  perhaps,  too  much  housework  besides,  or  to 
too  close  confinement  indoors  with  monotonous  housework.  Close  confinement  in 
the  house,  with  the  same  round  of  housework  day  after  day  and  month  after 
month,  without  a  diverting  change  of  work  or  a  stimulating  object  to  be  attained, 
is  enough  to  produce  digestive  disturbance,  malnutrition,  anemia  and  general 
depression,  both  physical  and  mental.  In  the  same  way  the  woman  who  devotes 
her  time  largely  to  society  may,  by  the  constantly  repeated  round  of  social  ex- 
actions, become  completely  ' '  fagged  out. ' '  Also,  the  woman  who  does  office  work 
may  be  worn  out  by  having  to  do  the  same  work  day  after  day  for  months  and 
years. 


AMENORRHEA  987 

In  all  such  cases,  besides  the  regular  tonic  course,  a  change  or  break  in  the 
regular  routine  is  advisable.  This  change  should  be  a  decided  one.  It  should 
produce  not  only  a  change  in  physical  activity,  but  also  should  change  the  current 
of  thought  and  furnish  a  new  direction  for  mental  activity.  The  prescription  to 
bring  about  these  changes  will  vary  much  in  different  cases,  depending  to  a  large 
extent  on  the  circumstances  and  inclinations  of  the  patient.  "With  some  it  will 
be  a  prolonged  trip  abroad,  leisurely  visiting  places  of  interest;  with  others,  a 
trip  to  the  seashore  or  to  the  mountains  for  a  few  weeks  or  several  months.  In 
the  cold,  cloudy  months  of  the  winter  a  sojourn  in  the  South  may  be  advisable ; 
while,  to  escape  the  heat  of  summer,  the  northern  lake  resorts  are  available  in 
addition  to  the  mountains  and  the  seashore.  In  other  cases  a  few  weeks'  rest  in 
the  country  will  answer  the  purpose,  or  a  prolonged  visit  with  friends  in  another 
<;ity,  or  the  employment  of  help,  so  that  the  patient  has  less  routine  housework  or 
office  work,  and  more  time  for  rest,  amusement,  outdoor  exercise  and  some  divert- 
ing leisure  pursuit,  such  as  photography,  painting,  music,  fancy  work,  or  one  of 
the  many  other  things  which  furnish  physical  and  mental  diversion.  A  change  of 
thought  and  action  for  a  few  weeks  or  a  few  months,  as  the  case  may  be,  is  one  of 
the  best  tonics,  and,  w^hen  combined  with  suitable  medication  and  hygiene,  it 
may  make  one  ''feel  like  a  new  person."  The  regular  work  can  then  be  taken  up 
with  interest  and  pleasure,  and  can  be  executed  with  vigor  and  satisfaction.  Keep 
in  mind,  however,  that,  to  continue  in  good  health,  the  patient  must  take  time 
for  rest,  nourishment,  exercise  and  relaxation. 

Obesity.  When  the  patient  is  considerably  heavier  than  she  should  be, 
particularly  if  she  has  increased  in  weight  recently,  she  should  be  placed  on 
treatment  for  correcting  the  faulty  metabolism  that  results  in  fat  deposition. 
The  systematic  treatment  of  this  condition  belongs  to  general  medicine  and 
<3an  not  be  considered  in  detail  here.  The  author  has  obtained  good  results  in 
these  cases  from  the  granular  effervescent  Vichy  and  Kissingen  salts  given  on 
alternate  days — one  day  the  Vichy  and  the  next  day  the  Kissingen,  etc.  This 
should  be  continued  for  two  or  three  months  and  combined  with  a  more  or  less 
strict  diet.  Even  w^hen  the  weight  is  not  noticeably  reduced,  the  metabolism 
is  improved,  the  patient  is  placed  in  better  general  health  and  hence  in  better 
condition  for  menstruation.  Of  course,  when  the  stout  patient  is  anemic,  she 
requires  a  course  of  iron  along  with  the  other  treatment.  The  value  of  certain 
organo-therapeutic  preparations  is  discussed  in  next  chapter. 

When  the  amenorrhea  is  apparently  due  to  nervous  impressions  (a  long 
journey,  change  of  environment,  grief,  joy,  anxiety),  no  treatment  is  required 
-except  for  accompanying  disturbances.  When  the  patient  becomes  accustomed 
to  her  new  surroundings,  the  menses  will  probably  return.  In  the  meantime 
any  symptomatic  disturbance  should  be  treated — a  sedative  if  needed,  a  tonic 
if  indicated,  an  emmenagogue  at  once  if  thought  best,  or  later  if  the  menses 
do  not  appear. 

9.  Suppression  of  the  Menses  requires  rather  active  treatment.    First  satisfy 


988  DISTURBANCES    OF   FUNCTION 

yourself  that  you  are  not  being  deceived;  i.  e.,  tliat  no  pregnancy  is  present- 
Then  employ  measures  to  produce  pelvic  congestion  and  to  overcome  the  nerv- 
ous inhibitory  injluence  which  has  been  started  by  exposure  to  cold  or  nervous 
shock,  or  whatever  it  was  that  caused  the  sudden  suppression  of  the  flow.  If 
the  patient  is  very  nervous  or  in  pain,  give  sedatives  in  sufficient  doses  to  set  the 
nerves  at  rest.  Have  the  patient  take  a  warm  sitz-bath  (a  mustard  foot  bath 
may  be  given  at  the  same  time),  then  have  her  go  to  bed,  covered  up  warmly 
and  hot  applications  made  to  the  lower  abdomen  and  genitals.  Hot  drinks, 
that  tend  to  start  up  the  secretory  action  of  the  skin  and  other  organs,  are 
then  advisable.  If  the  bowels  have  not  moved  well,  order  a  large  enema  of 
warm  Avater  or  warm  soap  water. 

Medication  will  be  largely  symptomatic.  In  sudden  suppression  of 
the  menstrual  flow  (from  exposure  to  cold  or  nervous  shock),  accompanied  by 
full  pulse  and  feeling  of  fullness  in  the  head  and  in  the  pelvis,  give  drop  doses 
of  tincture  of  aconite  every  half  hour  until  the  circulatory  tension  is  relieved. 
Used  in  conjunction  with  the  measures  above  mentioned,  this  often  causes  the 
flow  to  return  in  a  few  hours.  Tincture  of  Pulsatilla,  given  in  two-drop  doses 
every  3  hours,  is  sometimes  effective  in  relieving  the  distress  and  restoring  the 
flow.    If  there  is  severe  pain,  phenacetin  and  codeine  may  be  required. 

SCANTY  MENSTRUATION 

A  diminution  in  the  menstrual  flow,  or  a  too  slight  flow  from  the  beginning 
of  menstruation,  is  caused  by  the  same  condition  that  leads  to  absence  of  the 
menses  (with  the  exception  of  those  obstructive  lesions  that  prevent  the  escape 
of  any  blood),  and  the  treatment  also  is  practically  the  same. 

EXCESSIVE  MENSTRUATION  (MENORRHAGIA) 

The  menstrual  flow  may  be  too  free  or  it  may  last  too  long.  In  either  case 
the  condition  is  known  as  excessive  menstruation  or  menorrhagia.  The  nor- 
mal duration  of  the  flow  and  the  amount  of  blood  lost  varies  much  in  different 
patients.  With  each  patient,  however,  the  duration  of  the  menstrual  flow  and 
the  amount  of  blood  lost  is  fairly  constant — that  is,  the  patient  menstruates 
about  the  same  length  of  time  and  loses  about  the  same  amount  of  blood  at  each 
normal  menstruation.  If  there  is  decided  increase  in  the  amount  or  in  the 
duration  of  the  flow,  the  patient  may  be  said  to  menstruate  excessively,  though 
the  same  amount  and  duration  of  the  flow  in  another  individual  might  be 
normal  if  usual  with  her.  Each  patient  is  somewhat  of  a  law  unto  herself  in 
this  respect.  Therefore,  to  make  the  diagnosis  of  excessive  menstruation,  we 
need  to  know  something  of  the  patient's  menstrual  history. 

Etiology 

Excessive  menstruation  is  due  to  those  conditions  which  cause  congestion 


MENORRHAGIA  989 

of  the  pelvis,  especially  those  which  cause  congestion  of  the  uterine  mucosa. 
It  may  be  caused  by  any  of  the  following  conditions: 

1.  Hyperplasia  of  the  Endometrium.  This  is  the  usual  cause  of  menor- 
rhagia  occurring  in  virgins.  As  explained  in  a  previous  chapter  (page  628), 
this  anomaly  is  not  real  inflammation,  but  is  simply  a  nutritive  change  caused 
by  ovarian  hyperactivity. 

2.  Infected  Endometritis.  Inflammation  of  the  uterus,  either  acute  or 
chronic,  tends  to  cause  uterine  congestion  and  consequent  increase  of  the 
menstrual  flow.  Also  in  these  cases  the  increased  menstrual  flow  is  really  but 
the  expression  of  hyperfunction  of  the  ovaries,  caused  by  their  irritation  as  the 
result  of  the  inflammatory  process  (see  Chapter  xv). 

3.  Subinvolution,  without  infection,  is  a  rather  frequent  cause  of  prolonga- 
tion of  the  bloody  lochia  after  childbirth,  and  of  excessive  menstruation  later. 

4.  Malposition  of  Uterus,  particularly  marked  retrodisplacement,  often  is 
associated  with  excessive  menstruation — in  fact,  this  is  one  of  the  prominent  symp- 
toms in  a  large  proportion  of  the  cases  of  backward  displacement  of  the  uterus 
(page  674). 

5.  Cervical  Poljrpi  may  cause  excessive  menstruation  and  also  bleeding  be- 
tween the  menses.  It  is  surprising  how  much  bleeding  Avill  be  caused  in  some 
cases  by  one  or  two  small  polypi  in  the  cervix. 

6.  Fibromyoma  of  Uterus  causes  menorrhagia  when  intramural  or  sub- 
mucous. This  excessive  loss  of  blood  during  menstruation  is  one  of  the  promi- 
nent symptoms  of  fibroid  (page  723)  and  is  rarely  absent  in  the  classes  men- 
tioned. 

7.  Cancer  of  Uterus.  Malignant  disease  of  the  uterus  in  any  form,  whether 
affecting  the  cervix  or  the  corpus  uteri,  is  likely  after  a  time  to  show  profuse 
menstrual  bleeding.  In  the  early  stage,  however,  the  bleeding  is  more  likely 
to  appear  as  an  occasional  streak  of  blood  between  the  menses,  noticed  after 
coitus  or  after  forced  walking  or  lifting  (page  766). 

8.  Pelvic  Inflammation,  both  acute  and  chronic,  causes  periuterine  and 
uterine  congestion,  with  resulting  excessive  menstruation. 

9.  Ovarian  and  Broad  Ligament  Tumors  interfere  with  the  return  of  blood 
from  the  uterus  and  thus  may  cause  uterine  congestion,  with  resulting  ex- 
cessive menstruation. 

10.  Obstructive  Diseases.  Diseases  that  interfere  with  the  return  of  blood 
from  the  pelvis,  such  as  heart  disease  with  failing  compensation,  obstructive 
liver  diseases  and  abdominal  tumors,  necessarily  tend  to  uterine  congestion  and 
consequent  menorrhagia. 

Diseases  that  cause  frequent  straining  efforts,  such  as  constipation,  chronic 
diarrhea,  stricture  of  rectum  and  chronic  cystitis,  lead  to  pelvic  congestion 
and  excessive  menstrual  flow. 

11.  Functional  Pelvic  Congestion.  In  some  cases  no  lesion  is  found  on  ex- 
amination and  the  prolonged  menstruation  is  evidently  due  simply  to  functional 


990  DISTURBANCES   OF   FUNCTION 

pelvic  congestion.    This  functional  pelvic  congestion  may  be  caused  by  many 
conditions,  among  which  are  the  following: 

a.  Work  that  favors  pelvic  congestion,  such  as  standing  for  hours  (as  clerks 
must  do),  or  running  a  sewing  machine  for  hours  (as  is  done  by  the  seamstress),. 
or  lifting  and  working  about  the  sick  (as  is  done  by  the  nurse),  may  lead  to 
excessive  menstruation.  Long  automobile  rides  over  rough  roads  might  be 
mentioned  in  this  connection. 

b.  Excessive  or  violent  exercise,  as  is  sometimes  taken  in  the  excitement 
of  outdoor  sports. 

c.  Recent jn.arri^ge.  In  the  first  few  months  after  marriage  there  is  fre- 
quently some  increase  in  the  menstrual  flow,  but  ordinarily  it  need  cause  no 
alarm,  for  it  usually  disappears  as  the  pelvic  organs  become  accustomed  to 
the  changed  conditions. 

It  must  be  kept  in  mind,  also,  that  an  early  abortion  coming  about  the  men- 
strual time,  or  an  early  tubal  pregnancy  with  rupture  or  tubal  abortion  at  the 
menstrual  time,  may  very  closely  resemble  an  ordinary  menorrhagia,  with  some 
extra  pain  and  a  few  blood  clots. 

Treatment 

It  is  convenient  to  divide  the  treatment  into  (A)  treatment  during  the  flo^v 
and  (B)  treatment  between  the  periods. 

(A)  Treatment  During  the  Flow 

You  are  called  to  see  a  patient  who  is  menstruating,  the  flow  being  too  free 
or  having  lasted  too  long.  By  questioning  the  patient  it  can  usually  be  de- 
termined certainly  that  it  is  a  regular  menstrual  flow  and  not  bleeding  con- 
nected with  an  early  abortion  or  threatened  abortion,  or  tubal  pregnancy.  As 
the  patient  is  menstruating,  of  course,  no  examination  is  made  unless  there  are 
indications  of  serious  trouble.  If  the  questioning  shows  clearly  that  the  trouble 
is  simply  excessive  or  prolonged  menstruation,  the  patient  may  be  given  some 
uterine  astringent  internally. 

1.  Internal  Uterine  Astring-ents.  Ergot,  in  its  various  forms,  is  one  of  the 
most  reliable  of  the  uterine  hemostatics  for  internal  use.  A  satisfactory  way 
of  administering  it  is  ergotin  and  nux  vomica  in  a  capsule.  Or  the  fluid  extract 
or  other  preparations  may  be  given.  Ergot  is  efficient  in  all  forms  of  uterine 
bleeding,  except  when  pregnancy  is  present.  It  must  never  be  given  when 
there  is  a  suspicion  of  pregnancy. 

Another  reliable  uterine  hemostatic  is  stypticin.  It  may  be  in  the  pre- 
pared %  gr.  tablets.  The  author  usually  prescribes  it  in  1/2  gr.  to  1  gr.  doses, 
in  combination  with  ergotin  in  capsules,  one  capsule  to  be  taken  every  4  to  8  hours, 
depending  on  the  amount  necessary  to  control  the  bleeding  Stypticin  is 
cotarnine  hydrochloride.    Cotarnine  is  derived  from  narcotine,  which  is  a  prod- 


MENORRHAGIA  991 

uct  of  opium.  Stypticin  is  a  yellow  powder  of  very  bitter  taste.  It  is  con- 
veniently given  in  eapsnles.  It  is  expensive  to  the  patient,  and,  for  that  reason, 
it  is  preferable  to  give  the  ergotin  eapsnles  for  the  intermenstrual  period  and 
the  stypticin  only  during  the  flow.  A  later  and  allied  product  is  styptol,  a  com- 
bination of  cotarnine  with  phthalic  acid.  It  has  about  the  same  action  and  indi- 
cations and  dosage  as  stypticin. 

Hydrastinine,  an  alkaloid  from  hydrastis  and  closely  allied  chemically  to 
stypticin,  is  frequently  used  to  check  menorrhagia.  It  is  expensive.  Calcium 
chloride,  also,  is  used  as  an  internal  hemostatic.  Strychnia  and  other  tonics 
tend  to  tone  up  relaxed  muscular  tissue  and  may  thus  diminish  bleeding. 

2.  Laxatives.  At  the  beginning  of  the  treatment  the  bowels  should  be 
moved  well  with  a  saline  purgative,  and  after  that  laxatives  should  be  given  as 
needed  to  secure  one  or  two  good  bowel  movements  daily. 

3.  Rest  in  Bed.  The  patient  should  stay  in  bed  during  the  flow  if  possible. 
If  the  bleeding  is  at  all  severe,  this  is  imperative. 

The  employment  of  the  three  measures  above  mentioned  will  usually 
diminish  the  flow  decidedly  within  twenty-four  hours. 

4.  Sedatives.  If  the  patient  is  nervous  and  restless  or  if  there  is  dys- 
menorrhea (a  very  frequent  accompaniment  of  menorrhagia),  give  potassium 
bromide,  15  gr.  every  3  hours,  as  needed  to  give  rest  and  sleep.  This  makes  the 
patient  much  more  comfortable,  and,  in  addition,  the  bromides  (particularly 
potassium  bromide)  are  supposed  to  aid  somewhat  in  checking  excessive  men- 
strual flow. 

If  the  pain  is  severe,  the  bromides  will  probably  not  be  sufficient  to  relieve 
it,  and  then  opium  is  indicated.  Besides  checking  the  patient's  sufferings,  the 
opium  has  a  decided  effect  toward  temporarily  checking  the  uterine  bleeding. 
When  opium  is  given,  it  should  be  in  such  form  that  the  patient  does  not  know 
what  she  is  taking.  A  very  good  formula  is  ergot  in  one  grain  and  opium  one- 
half  grain,  given  in  a  pill  and  repeated  every  six  to  eight  hours  as  needed. 

5.  Medicine  for  Special  Indications.  If  there  is  heart  trouble  with  failing 
compensation,  digitalis  or  other  heart  stimulant  is  indicated. 

If  there  is  a  troublesome  cough,  or  bladder  or  rectal  disturbance,  or  other 
affection,  give  medicine  for  the  same. 

6.  Vaginal  Tamponade.  Another  method  and  a  yery  efficient  one  for  tem- 
porarily checking  a  serious  loss  of  blood  during  menstruation  is  to  tampon 
the  vagina  flrmly,  the  same  as  for  hemorrhage  from  any  other  cause.  This 
temporarily  stops  the  loss  of  blood  from  the  relaxed  atonic  uterus  and  pre- 
serves that  much  for  the  anemic  patient,  who  can  ill  afford  to  lose  it.  This  pack- 
ing may  be  removed  in  one  or  two  days,  and  another  applied. 

The  systematic  use  of  this  method  in  suitable  cases  was  brought  before  the 
profession  by  Gehrung,  who,  from  an  extensive  experience  with  it,  states  that 
no  ill  effect  follows  this  arbitrary  checking  of  the  menstrual  flow  after  a  proper 
amount  of  blood  has  been  lost.    It  is  a  useful  temporary  expedient  for  preserving 


992  DISTURBANCES    OF   FUNCTION 

to  the  anemic  patient,  over  a  few  menstrual  periods,  the  blood  which  she  can  ill 
afford  to  lose  by  stopping  the  flow  after  the  third  or  fourth  day  of  menstruation. 
In  this  way  the  downward  course  of  the  trouble  may  be  checked  and  the 
patient's  condition  held  stationary,  while  other  measures  are  employed  to  over- 
come the  cause  of  the  excessive  menstruation. 

(B)   Treatment  Between  Menstrual  Periods 

Having-  checked  the  flow  temporarily,  the  next  thing  is  to  prevent  the  re- 
currence of  the  excessive  menstruation.     The  indications  in  such  cases  are: 
To  reduce  congestion  of  the  uterus  and  other  pelvic  structures,  espe- 
cially ovaries. 
To  tone  up  the  uterus. 

To  put  the  patient's  blood  in  good  condition. 
To  correct  local  diseases. 
The  measures  for  accomplishing  these  objects  are  as  follows: 

1.  Laxatives.  There  should  be  one  or  two  good  bowel  movements  daily, 
and  at  the  menstrual  period  the  bowels  should  be  given  a  special  clearing  out. 

2.  Uterine  Tonics.  Ergot  is  one  of  the  best  drugs  for  toning  up  an  atonic 
uterus.  It  produces  also  some  constriction-  of  the  blood  vessels  and  thus  dimin- 
ishes the  amount  of  blood  in  the  organ.  This  has  a  marked  effect  in  checking 
excessive  loss  of  blood.  The  ergotin  and  nux  vomica  combination  is  an  excellent 
form  in  which  to  give  the  ergot.  It  is  a  good  general  tonic.  At  the  menstrual 
period  it  is  well  to  increase  the  frequency  to  every  6  hours. 

Stypticin,  styptol  or  other  hemostatics  mentioned  under  ' '  Treatment  Dur- 
ing the  Flow,"  may  be  administered  during  the  intermenstrual  period. 

3.  General  Tonic  Remedies.  Menorrhagia  is  not  a  disease.  It  is  only  a 
symptom,  and  the  physician  must  find  what  is  back  of  it  as  an  etiologic  factor. 

If  anemia  is  present,  the  cause  must  be  sought  and  the  patient  placed  on 
the  required  tonic  regimen  and  medication. 

If  there  is  heart  disease,  portal  obstruction  or  any  other  condition  that 
interferes  with  the  return  of  blood  from  the  pelvis,  it  must  receive  appropriate 
treatment. 

4.  Correction  of  Local  Disturbances.  Any  local  disease  present  should  be 
determined  and  treatment  instituted  accordingly.  This  is  a  very  important  part 
of  the  treatment  of  menorrhagia  and  tends  more  than  anythng  else  to  bring 
about  a  permanent  cure.  The  pelvic  disorders  that  may  cause  menorrhagia 
have  just  been  enumerated  and  the  various  methods  of  treatment  are  given  in 
the  appropriate  chapters. 

Often  the  correction  of  a  retrodisplacement  and  the  retention  of  the  uterus 
in  proper  position,  by  pessary  or  otherwise,  will  effect  a  cure  of  menorrhagia. 

In  some  cases  of  hyperplasia  of  the  endometrium  or  endometritis  or  sub- 
involution or  fibromyoma,  astringent  intrauterine  applicationsj  made  once  or 
tAvice  Aveekly  in  the  intermenstrual  period,  may  suffice  to  overcome  the  exces- 


DYSMENORRHEA  993 

sive  menstrual  flow.  In  other  cases  it  may  be  desirable  to  employ  curetmeiit. 
Intrauterine  treatment  (applications  or  curetment)  should  always  be  accom- 
j)anied  by  such  assisting  measures  as  are  indicated. 

Metrorrhagia  (bleeding  between  the  menses)  is  considered  on  page  1030. 

PAINFUL  MENSTRUATION  (DYSMENORRHEA) 

Dysmenorrhea  is  the  most  troublesome  of  the  menstrual  disturbances, 
causing  many  women  to  sutler  from  one  to  several  days  every  month.  In  some 
cases  the  suffering  is  so  severe  that  menstruation  constitutes  a  monthly  torture, 
which,  aside  from  the  immediate  pain,  leaves  the  patient  worn  and  weak  for 
many  days  afterwards,  and  she  lives  in  constant  dread  of  the  next  menstrual 
period.  Even  in  the  milder  cases  the  constant  recurrence  of  pain  and  physical 
and  mental  depression  may  gradually  induce  a  serious  condition  of  malnutrition 
and  neurasthenia. 

Dysmenorrhea  is  not  a  disease,  but  only  a  symptom.  It  is  caused  by  a 
great  variety  of  conditions  and  is  a  symptom  of  many  pelvic  diseases.  How- 
ever, no  one  organic  lesion  has  been  shown  to  be-  the  essential  or  sufficient 
cause  of  menstrual  pain,  for  every  condition  so  considered  at  one  time  or 
another  has  been  found  to  exist  in  some  instances  without  accompanying  men- 
strual pain. 

It  is  apparent  that  in  practically  every  case,  dysmenorrhea  is  due  to  a  com- 
bination of  abnormal  conditions,  either  local  or  general  or  both.  The  work  of 
the  physician  in  each  case  is  (a)  to  determine  the  abnormal  conditions  present 
in  that  particular  case,  (b)  to  form  an  estimate  of  the  relative  importance  of 
each  in  the  causation  of  the  menstrual  distress  and  (c)  to  treat  the  patient 
accordingly. 

It  has  been  customary  to  group  the  cases  of  dysmenorrhea  into  four 
classes  as  follows,  each  class  supposedly  representing  distinct  etiologic  factors: 

Neuralgic  or  Ovarian  Dysmenorrhea. 

Congestive    or   Inflammatory   Dysmenorrhea. 

Obstructive  or  Mechanical  Dysmenorrhea. 

Membranous   Dysmenorrhea. 
Neuralgic  Dysmenorrhea  is  simply  neuralgia  of  the  ovarian,  uterine  and 
other  pelvic  nerves,  coming  on  at  the  menstrual  period  because  of  the  in- 
creased pelvic  congestion  and  the  greater  impressionability  of  the  nervous 
system  generally  at  that  time. 

The  pain  is  neuralgic  in  character,  i.  e.,  sharp  and  variable.  It  radiates 
from  the  ovarian  region  of  one  or  both  sides  to  the  uterus  and  to  the  iliac, 
abdominal,  lumbar  and  sacral  region.  Not  infrequently  it  extends  down  the 
thighs.  In  a  large  proportion  of  the  cases  there  is  a  severe  attack  of  head- 
ache at  some  part  of  the  menstrual  epoch  and  occasionally  a  distinct  neural- 
gia in  some  other  part  of  the  body.  The  pain  appears  to  be  independent  of  the 
character  of  the  menstrual  flow.    It  may  be  most  intense  a  day  or  two  before 


994  DISTUEBANCES   OF   FUNCTION 

the  flow  or  it  may  come  on  after  the  flow,  or  it  may  come  and  go  during  the 
Avhole  time.  Thus  it  is  erratic  and  is  likely  to  vary  much  in  the  different 
menstrual  periods  without  apparent  cause. 

This  form  of  dysmenorrhea  occurs  usually  in  women  of  a  neuralgic  or 
rheumatic  diathesis.  Neuralgic  or  rheumatic  pains  are  often  felt  in  the  inter- 
menstrual periods,  either  in  the  pelvis  or  elsewhere.  Hyperesthesia  over 
the  abdominal  surface  and  pain  are  frequently  noticeable,  and  this  is  much 
increased  at  the  menstrual  time. 

This  form  of  dysmenorrhea  is  liable  to  be  associated  with  anemia,  in- 
digestion, neurasthenia,  hysteria  and  allied  disturbances.  Patients  with 
rheumatism  and  gout  are  also  particularly  prone  to  menstrual  pain  without 
apparent  causative  lesion  in  the  pelvis.  In  the  cases  of  so-called  "neuralgic" 
dysmenorrhea,  ovarian  pain  usually  plays  a  prominent  part — so  prominent 
that  this  is  sometimes  referred  to  as  ''ovarian  dysmenorrhea." 

Congestive  or  Inflammatory  Dysmenorrhea  is  due  to  congestion  within  the 
pelvis,  particularly  congestion  of  the  uterine  adnexa.  This  congestion  may  be 
due  to  some  inflammation  in  the  uterus  or  around  it,  or  it  may  be  due  to  some 
non-inflammatory  condition,  such  as  uterine  displacement,  or  a  tumor  of  the 
uterus  or  vicinity,  or  a  functional  pelvic  congestion  (page  989). 

The  pain  is  that  of  inflammation,  and  is  felt  as  a  soreness  or  throbbing 
pressure  in  the  pelvis  or  back.  It  may  radiate  into  the  iliac  regions,  or  up  the 
spine  or  down  the  thighs.  If  the  inflammation  is  pi?incipally  in  one  side  of  the 
pelvis,  the  pain  is  most  severe  there. 

The  pain  is  usually  most  severe  the  first  day  or  two  of  the  flow,  but  may 
last  all  the  time.  The  pain  may  begin  a  day  or  two  before  the  flow,  and  this 
is  especially  liable  to  occur  in  those  cases  of  inflammatory  trouble  involving  the 
ovary.  There  is  also  much  general  soreness  through  the  pelvis,  which  is  in- 
creased by  walking  or  standing. 

The  diagnostic  sign  of  this  variety  of  dysmenorrhea  is  the  character  and 
constancy  of  the  pain  and  the  fact  that  there  is  trouble  between  the  menses — 
evidence  of  inflammation  or  displacement,  or  tumor  or  something  that  keeps 
up  chronic  pelvic  congestion.  The  various  causes  of  pelvic  congestion  are 
mentioned  in  detail  under  menorrhagia  (page  990).     y 

Obstructive  or  Mechanical  Dysmenorrhea  is,  as  its  name  implies,  dependent 
on  the  obstruction  to  the  outflow  of  the  menstrual  blood.  The  obstruction  may 
be  due  to  circular  stenosis  of  the  canal  from  imperfect  development,  or  from 
cicatricial  narrowing  or  from  spasmodic  constriction  of  the  circular  muscle 
fibers,  or  from  swelling  of  the  uterine  mucosa.  It  may  be  due  also  to  a  sharp 
bend  in  the  canal  due  to  fiexion  of  the  uterus— usually  an  anteflexion,  occa- 
sionally a  retroflexion.  The  obstruction  is  usually  found  about  the  internal  os, 
though  in  very  exceptional  cases  it  may  be  at  some  other  point  along  the  canal 
or  at  the  external  os.  The  canal  may  be  narrowed  by  a  tumor  situated  in  the 
cervix  or  outside  the  uterus.  A  small  polypus  within  the  uterus  may  drop  into 
«r  against  the  internal  os  and  block  it.    Again,  the  menstrual  blood  may  con- 


DYSMENORRHEA  995 

tain  clots,  which  are  expelled  with  difficulty  even  when  the  canal  is  of  normal 
size. 

The  characteristic  of  mechanical  dysmenorrhea  is  that  the  pain  is  par- 
oxysmal in  character,  apparently  corresponding  to  painful  uterine  contrac- 
tions brought  about  by  the  effort  of  the  uterus  to  force  the  blood  past  the 
obstruction.  The  pains  are  periodical — ^^'ery  severe  at  times,  with  intervals  of 
rest  between — somewhat  on  the  order  of  the  pains  of  a  miscarriage.  "When 
the  menstrual  flow  is  freely  established,  the  severe  pain  usually  disappears. 

Dysmenorrhea  due  entirely  to  mechanical  causes,  or  obstruction,  is  rare. 
There  are  usually  comiolicating  conditions  that  are  as  important  as,  if  not  more 
important  than,  the  obstruction.  The  dysmenorrhea  of  young  women,  so 
frequently  associated  with  anteflexion,  was  for  a  long  time  supposed  to  be  due 
to  obstruction  in  the  canal.  But  it  is  now  kno-wni  that  the  obstruction  is  only 
one  of  the  factors,  and  in  most  cases  one  of  only  secondary  importance,  as  ex- 
plained later  (page  996). 

Membranous  Dysmenorrhea  is  the  term  applied  to  that  form  of  painful 
menstruation  accompanied  by  the  expulsion  of  membrane  from  the  uterus.  The 
membrane  is  usually  passed  in  small  pieces,  though  occasionally  it  is  thro^vn 
off  as  a  complete  cast  of  the  interior  of  the  uterus.  It  consists  of  the  super- 
ficial layers  of  the  uterine  mucous  membrane,  and  is  thrown  off  as  the  result 
of  nutritive  changes  which  are  not  yet  understood. 

The  pains  come  with  the  flow  and  are  paroxysmal — of  the  same  character 
as  the  pains  of  mechanical  dysmenorrhea,  but  very  severe,  resembling  labor 
pains.  After  these  have  continued  for  several  hours  or  a  day  or  two,  pieces  of 
the  membrane  are  expelled.  There  is  then  relief  unless  other  pieces  pass. 
The  membrane,  mixed  with  the  menstrual  flow,  is  the  diagnostic  sign  of  this 
form  of  dysmenorrhea.  Care  must  be  exercised  not  to  confound  it  with  mis- 
carriage. It  usually  recurs  every  month  or  so  and  may  last  for  years.  The 
cause  is  not  deflnitely  knoAvn. 

In  regard  to  the  above  classification,  with  the  exception  of  the  cases  of 
membranous  dysmenorrhea,  it  does  not  make  a  very  satisfactory  grouping  of 
the  cases.  In  a  few  patients  the  dysmenorrhea  apparently  belongs  entirely  to 
one  of  the  forms  mentioned;  i.  e.,  neuralgic  or  inflammatory  or  obstructive.  In 
most  cases,  however,  there  is  such  a  mixtiire  of  neuralgic,  congestive  and  ob- 
structive features  that  it  is  impossible  to  assign  the  case  exclusively  to  any 
one  of  these  classes.  For  the  purposes  of  diagnosis  and  treatment,  it  is  con- 
venient to  divide  the  cases  of  dysmenorrhea  into  two  groups — the  first  group 
including  the  cases  of  dysmenorrhea  in  the  virgin  and  the  second  group  includ- 
ing the  cases  of  dysmenorrhea  in  the  married  woman. 

(A)  DYSMENORRHEA  IN  THE  VIRGIN 

The  patient,  a  girl  or  unmarried  woman,  comes  complaining  of  pain  at  the 
menstrual  periods.    The  pain  may  be  so  severe  that  the  patient  is  obliged  to  go 


996  DISTURBANCES    OF   FUNCTION 

to  bed  for  one  or  two  or  three  days  at  each  menstrual  period,  or  it  may  be  less 
severe,  so  that  she  is  able  to  be  up  and  about,  but  is  miserable.  Sometimes 
the  pain  is  very  severe,  but  going  to  bed  gives  no  relief.  The  pain  may  have 
been  marked  from  the  first  menstruation  or  it  may  have  been  slight  at  first, 
with  gradual  increase  since.  There  is  usually  a  decided  difference  in  the  pain 
in  the  different  menstrual  periods,  being  much  more  troublesome  at  some  ■ 
periods  than  at  others.  In  many  cases  the  pain  begins  a  day  or  two  before 
the  flow.  It  is  usually  much  relieved  within  24  hours  after  the  flow  is  well 
established. 

Along  with  the  menstrual  pain  there  may  be  loss  of  appetite,  nausea, 
lassitude  and  neuralgias.  There  is  nearly  always  decided  weakness  during 
the  flow  and  for  one  to  several  days  thereafter.  Menstruation  may  be  other- 
wise normal,  or  there  may  be  scanty  menstruation  or  excessive  menstruation. 
In  many  cases  the  patient  has  no  particular  disturbance  during  the  inter- 
menstrual period. 

Causes  of  Dysmenorrhea  in  the  Virgin 

The  causes  are  varied,  but  there  is  one  group  of  conditions  that  overtops 
all  others  in  the  frequency  of  occurrence,  namely, 

1.  Neurotrophic  Dysmenorrhea.  In  the  majority  of  cases  of  dysmenor- 
rhea in  the  virgin  there  is  a  combination  of  conditions,  comprising  anteflex- 
ion of  the  cervix,  some  stenosis  of  the  cervical  canal  and  marked  hyperes- 
thesia of  the  uterine  tissues,  especially  in  the  neighborhood  of  the  internal 
OS.  This  condition  is  a  very  important  one  on  account  of  the  frequency  of  its 
occurrence  and  the  suffering  it  causes,  and  the  stubbornness  with  which  it 
resists  treatment  in  many  cases.  The  cause  of  the  pain  in  these  eases 
was  for  a  long  time  supposed  to  be  due  to  the  narrowing  of  the  canal  at 
the  internal  os  by  the  anteflexion  present  with  the  consequent  obstruction  to 
the  outflow  of  menstrual  blood.  That  the  obstruction  does  play  some  part  is 
shown  by  the  fact  that  when  the  obstruction  is  removed  the  pain  is  usually 
considerably  diminished.  But  simple  removal  of  the  obstruction  (dilatation  of 
cervical  canal)  does  not  always  relieve  the  patient  entirely,  and  in  some 
eases  the  relief  from  this  measure  is  slight  or  wanting,  showing  conclusively 
that  the  obstruction  is  not  the  only  factor  in  the  case.  Again,  it  is  a  matter 
of  common  observation  that  other  patients,  with  as  much  or  more  anteflexion 
and  obstruction  as  are  found  in  these  cases,  have  no  dysmenorrhea.  In  37 
cases  of  decided  anteflexion,  reported  by  Judd,  9  were  without  menstrual 
pain,  19  had  menstrual  pain  beginning  before  the  flow  and  9  had  only  premen- 
strual pain.  In  26  cases  of  anteflexion  in  the  unmarried  reported  by  Hyde,  5 
had  no  menstrual  ^ain,  20  had '  menstrual  pain  beginning  before  the  flow 
and  1  had  pain  only  after  the  flow.  So  the  essential  disturbance  must  be 
sought  further.  Endometritis  has  been  put  forward  as  the  cause  of  the  pain— 
at  least  of  that  portion  of  it  which  is  not  relieved  by  the  removal  of  the 


DYSMENORRHEA  997 

obstruction.  But  this  hypothesis  also  fails.  In  not  a  few  cases  of  dysmenorrhea 
persisting  after  dilatation  the  museosa,  removed  by  curetment,  has  been  found 
to  be  practically  normal.  On  the  other  hand,  many  patients  Avith  decided 
endometritis  have  no  particular  menstrual  pain. 

There  is  one  pathologic  condition  that  seems  to  be  fairly  constant  in  the 
class  of  cases  under  consideration,  and  that  is  hyperesthesia  or  marked  irrita- 
bility of  the  nerves  of  the  uterine  mucosa  and  muscles,  especially  in  the 
neighborhood  of  the  internal  os.  This  is  noticeable  on  sounding  the  uterus 
and  especially  on  dilating  the  internal  os  without  anesthesia.  It  is  indicated 
also  by  the  painful  muscular  contraction  or  uterine  "cramps"  occurring  with- 
out apparent  cause.  The  theory  that  the  essential  or  underlying  condition 
in  these  cases  is  hyperesthesia  of  the  mucosa  and  muscle  due  to  a  nutritive 
disturbance,  affecting  the  nerves  and  other  tissues,  seems  to  be  the  most  tenable 
one.  It  explains  better  than  any  other  hypothesis  yet  advanced  the  various 
phenomena  observed.  It  shows  why  the  symptoms  may  persist  to  a  greater  or 
less  extent  after  removal  of  the  obstruction  at  the  internal  os  and  after 
removal  of  the  hyperplastic  mucosa.  It  shows  why  the  symptoms  occur  in 
patients  with  no  obstruction  and  with  no  decided  structural  change  in  the 
mucosa.  It  shows  why  measures  directed  toward  improving  nutrition  and 
allaying  nerve  irritability  will  sometimes  produce  decided  improvement  with- 
out any  local  treatment.  In  short,  it  explains  what  has  already  been  worked 
out  clinically — that  the  narrowing  of  the  canal  and  thickening  of  the  endome- 
trium are  simply  complications  that  may  or  may  not  be  present.  When  they 
are  present  they  aggravate  the  trouble  and  require  treatment.  But  unless 
the  nutritive  disturbance  of  the  uterine- muscle  and  mucosa  is  also  improved 
sufficiently  to  restore  the  nerves  to  fairly  normal  condition,  the  pain  will  con- 
tinue to  a  considerable  extent. 

The  marked  effect  of  pregnancy  and  parturition  in  these  cases  points 
strongly  to  its  being  largely  a  nutritive  disturbance.  Pregnancy  has  a  most 
profound  influence,  upon  the  nutrition  of  the  uterus.  To  be  sure,  the  parturi- 
tion eft'ectively- overcomes  the  stenosis,  but  this  does  not  account  for  the  uni- 
form and  marked  benefit,  for  we  have  already  found  that  in  many  cases  the 
stenosis  is  not  an  important  factor.  The  beneficial  effect  of  curettage  in 
these  cases  is  likcAvise  due,  to  a  large  extent,  to  its  marked  stimulation  of 
the  nutrition  of  the  uterus. 

Another  point  in  favor  of  the  supposition  that  this  trouble  is  essentially 
a  nutritive  disturbance  affecting  the  whole  uterus  (both  muscular  tissue  and 
mucosa)  is  the  fact  that  it  is  very  freqently  accompanied  by  evidences  of 
imperfect  development.  Such  cases  are  referred  to  as  cases  of  ''infantile 
uterus."  The  evidences  of  imperfect  development  are  late  beginning  of  the 
menses,  irregular  menstruation  and  decided  anteflexion  of  the  cervix  (failure 
of  the  cervix  to  take  its  proper  direction  across  the  vaginal  canal).  In  fact, 
the  association  of  imperfect  development  Avith  this  form  of  dysmenorrhea 
is  so  common  that  some  writers  attribute  the  dysmenorrhea  to   the  imper- 


998  DISTURBANCES   OF   FUNCTION 

feet  development.  It  seems,  however,  that  a  better  view  of  the  matter  is 
that  the  imperfect  development  and  the  dysmenorrhea  are  both  due  to  the 
same  cause — viz.,  poor  nutrition.  How  far  this  condition  may  be  the  result  of 
ovarian  hypofunction  shall  be  discussed  in  the  next  chapter. 

We  may  go  a  step  further  and  say  that  these  two  conditions — ^imperfect 
development  and  neurotrophic  dysmenorrhea — are  due  to  poor  nutrition  largely 
at  a  certain  period  of  life — ^namely,  at  the  period  of  puberty.  The  victims  who 
suffer  most  are  usually  women  who  during  puberty  were  poorly  nourished  from 
a  physical  and  developmental  standpoint,  and  Avere  subjected  to  influences  that 
would  retard  uterine  development  (see  page  979) .  In  many  cases  this  poor  nutri- 
tion persists,  and  is  only  too  apparent  when  the  patient  comes  to  the  physician 
to  secure  relief  from  the  dysmenorrhea.  In  other  cases  the  patient,  having  been 
for  some  time  out  of  school  and  taking  more  fresh  air  and  sunshine  and 
exercise,  has  acquired  good  blood  and  a  good  color.  But  that  has  not  been 
sufficient  to  correct  the  evil  effects  of  a  pernicious  regimen  during  puberty — a 
regimen  which  promoted  mental  activity  at  the  expense  of  physical  devel- 
opment. 

2.  Membranous  Dysmenorrhea.  This  form  of  dysmorrhea,  or  rather  the 
meaning  of  the  term,  has  been  explained.  The  cause  and  exact  pathology  are 
still  in  doubt.  It  is  sometimes  designated  as  ' '  exfoliative  endometritis, ' '  though 
careful  examination  of  the  exfoliated  membrane  has  shown  that  in  some 
cases  no  endometritis  is  present ;  e.  g.,  by  Ehrenf est  (American  Journal  of 
Obstetrics,  1908). 

Membranous  dysmenorrhea  is  a  comparatively  rare  affection.  It  usually 
appears  early  in  sexual  life,  though  some  cases  have  been  reported  in  which 
the  disease  first  appeared  in  middle  life.  It  usually  extends  over  several 
years.  At  certain  menstrual  periods  the  endometrium  is  cast  off  and  appears 
in  the  menstrual  discharge  as  shreds.  Occasionally  the  mucosa  is  cast  off  as 
one  piece,  forming  a  cast  of  the  uterine  cavity.  The  detachment  and  ex- 
pulsion of  a  membrane  with  the  menstrual  flow  (decidua  menstrualis)  may  take 
place  when  the  endometrium  is  practically  normal  in  structure  or  when  it  is 
the  seat  of  one  or  more  of  the  several  inflammatory  and  nutritive  changes 
already  described.  The  expelled  pieces  will,  of  course,  exhibit  whatever  struc- 
tural change  is  present  in  the  endometrium ;  consequently  in  a  series  of  cases 
of  membranous  dysmenorrhea,  examination  of  the  membrane  may  show  many 
different  inflammatory  and  nutritive  changes,  none  of  which  are  peculiar  nor 
distinctive  of  membranous  dysmenorrhea,  but  due  to  independent  patho- 
logic conditions  in  the  endometrium  are  only  accidental  findings. 

Membranous  dysmenorrhea  is  undoubtedly  due  to  a  marked  nutritive 
change,  but  just  what  lies  back  of  this  nutritive  change  has  not  been  certainly 
determined.  Lawrence,  in  reporting  a  number  of  cases,  advanced  the  idea 
that  the  condition  is  usually  due  to  pelvic  inflammation  following  an  attack 
of  one  of  the  exanthemata  near  puberty.  He  reported  42  cases  of  membranous 
dysmenorrhea  in  which  there  was  present  tubal  or  ovarian  disease  requiring 


DTSMENOERHEA  999 

operation.  In  19  cases  the  disease  was  unilateral  and  in  the  remaining 
bilateral.  In  33  of  the  42  cases  the  trouble  appeared,  from  the  history,  to 
have  started  from  an  attack  of  scarlatina,  measles,  mumps,  rheumatism  or 
small-pox.  In  nearly  all  (the  report  is  not  definite)  there  was  no  further 
membranous  dysmenorrhea  after  the  removal  of  the  pelvic  disease.  He  con- 
cludes that  membranous  dysmenorrhea  is  due  to  trophic  changes  in  the 
endometrium  secondary  to  adnexal  disease,  and  that  this  adnexal  disease  is 
usually  a  sequel  of  one  of  the  exanthemata  occurring  near  puberty.  He  con- 
cludes also  that  the  adnexal  disease  is  usually  unilateral  at  first  and  may  be 
prevented  from  extending  to  the  other  side  by  prompt  attention.  As  a  result 
of  these  conclusions,  he  holds  (a)  that  tubal  and  ovarian  complications  occur- 
ring with  the  exanthemata  near  puberty  should  be  watched  for  and  treated, 
(b)  that  in  every  case  of  membranous  dysmenorrhea  a  careful  history  should 
be  obtained  with  that  point  in  view,  (c)  that  when  unilateral  adnexal  disease 
is  found,  prompt  operation  should  be  carried  out  to  prevent  the  trouble  be- 
coming bilateral,  and  (d)  that  the  facts  in  the  case  ''would  seem  to  warrant 
removal  of  the  tubes  and  ovaries  on  one  or  both  sides  when  shreds  or  casts 
are  a  part  of  painful  menstruation. ' ' 

The  facts  brought  out  above  are  certainly  interesting,  and  study  along 
this  line  may  help  to  clear  up  part  of  this  subject.  With  the  last  conclusion, 
however,  the  author  must  differ  most  decidedly.  Removal  of  the  adnexa  on  one 
or  both  sides  should,  as  a  rule,  be  made  only  for  a  distinct  adnexal  lesion  and 
not  simply  for  painful  menstruation,  whether  accompanied  by  shreds  or  not 
(page  1007).  The  fallacy  of  operating  simply  for  the  dysmenorrhea  is  shown 
by  the  fact  that  the  dysmenorrhea  may  be  as  severe  after  operation  as  before. 
This  fact  was  brought  out  in  the  discussion  of  the  above  paper  by  L.  H. 
Dunning,  who  stated  that  "one  of  the  most  severe  cases  of  membranous 
dysmenorrhea  he  ever  saw  occurred  in  a  woman  after  he  had  removed  bilat- 
eral pus  tubes  and  both  ovaries.  She  menstruated  for  two  years  afterward 
and  had  membranous  dysmenorrhea."  In  a  previous  paper  Dr.  Dunning  had 
reported  a  case  of  membranous  dysmenorrhea  which  persisted  after  abdominal 
section  and  treatment  of  the  adnexal  disease,  and  finally  yielded  to  intrauterine 
applications  of  electricity. 

Concerning  diagnosis  of  membranous  dysmenorrhea  in  the  virgin,  the 
passage  of  shreds  of  membrane  with  the  menstrual  flow  establishes  the 
diagnosis.  There  is  no  other  affection  of  virgins  presenting  such  symptoms. 
It  is  well,  however,  to  have  some  of  the  membrane  s^ved  for  inspection  and 
microscopic  examination,  for  the  patient  may  be  deceived  by  blood  clots  or 
shreds  of  bloody  mucus.  It  must  be  kept  in  mind,  also,  that  in  certain  cases 
the  supposed  virgin  may  not  be  a  virgin,  and  that,  consequently,  the  sup- 
posed "decidua  menstrualis"  may  be  a  decidua  of  a  different  character  (page 
983). 

3.  Atrophy  of  Uterus.  In  certain  eases  in  virgins  past  30  years  of  age 
and  also  in  sterile  married  women  there  seems  to  be  some  atrophy  of  the 


1000  DISTURBANCES    OF    FUNCTION 

Uterus,  which  has  failed  to  receive  the  stimulus  of  pregnancy.  The  patient 
had  no  particular  pain  in  her  earlier  years,  but  gradually  menstrual  suffering 
has  appeared,  and  examination  shows  no  lesion,  except  a  rather  small  atrophic 
cervix,  with  more  or  less  stenosis.  This  is  really  a  form  of  neurotrophic  dys- 
menorrhea, but  is  due  to  trophic  disturbance  in  later  years  instead  of  during 
the  developmental  period.  This  is  one  of  the  classes  in  which  the  stem  pessary 
is  sometimes  advisable  (page  1007). 

4.  Backward  Displacement  of  the  Uterus.  Painful  menstruation  is  one  of 
the  symptoms  frequently  produced  by  marked  retrodisplacement  of  the  uterus. 
Kelly  found  that  of  229  consecutive  cases  of  dysmenorrhea  admitted  to  Johns 
Hopkins  Hospital,  41  per  cent  were  associated  ^^ith  retrodisplacement  of  the 
uterus,  37  per  cent  with  pelvic  inflammatory  disease,  and  11  per  cent  with 
fibromyomata.  The  proportion  of  cases  of  retrodisplacement  is,  of  course,  much 
larger  in  patients  who  have  borne  children  than  in  virgins.  In  184  cases  of 
retrodisplacement  of  the  uterus,  reported  by  A.  M.  Judd,  108  suffered  with 
menstrual  pain,  either  during  the  flow  or  immediately  before  it.  A  slight  retro- 
displacement of  the  uterus,  less  than  the  second  degree,  does  not  give  rise  to 
particular  disturbance  and  should  not  be  accepted  as  the  cause  of  dysmenorrhea. 

5.  Fibromyomata  of  the  Uterus.  Painful  menstruation  is  a  frequent  symp- 
tom in  uterine  myomata,  particularly  when  the  nodules  are  interstitial  or 
submucous. 

6.  Chronic  Pelvic  Inflammation  (salpingitis,  oophoritis,  cystic  ovary).  Sal- 
pingitis is  comparatively  rare  in  the  virgin,  for  the  various  causes  of  pelvic 
inflammation  in  the  married  woman  are  not  present.  Chronic  oophoritis 
from  local  circulatory  and  nutritive  disturbance  is  more  frequent  and  may 
give  rise  to  some  dysmenorrhea. 

7.  Pelvic  Tuberculosis.  This  is  not  so  rare  as  was  formerly  supposed,  and 
should  be  thought  of  vrhenever  there  are  evidences  of  chronic  pelvic  inflam- 
mation in  a  virgin. 

8.  Ovarian  or  Broad  Ligament  Tumors.  These  may  arise  in  the  virgin  and 
give  rise  to  the  usual  symptoms  and  signs,  which  are  detailed  in  the  appro- 
priate chapter. 

9.  Inflammation  of  Adjacent  Organs — bladder,  rectum,  appendix.  Any 
adjacent  inflammatory  trouble  is  likely  to  be  considerably  aggravated  by  the 
menstrual  congestion.  Occasionally  the  trouble  is  so  slight  as  to  be  hardly 
noticeable  except  during  the  menstrual  exacerbation.  In  such  a  case  it  may 
at  flrst  be  considered  one  of  the  usual  varieties  of  dysmenorrhea,  but  careful 
watching  Avill  show  symptoms  pointing  to  the  organ  involved,  and  evidence 
of  such  disturbance  may  be  found  in  the  intermenstrual  period.  Chronic  appen- 
dicitis not  infrequently  presents  decided  menstrual  exacerbations,  and  in 
some  cases  the  intermenstrual  symptoms  are  so  slight  or  indefinite  that  the 
true  nature  of  the  affection  is  not  suspected  until  abdominal  examination  shows 
tenderness  at  McBurney's  point  and  other  evidences  of  chronic  appendicitis. 

10.  Functional  Pelvic  Congestion.     Chronic  functional  congestion  of  the 


DYSMENORRHEA  1001 

pelvis,   due  to  constant  standing,   long  walking   or  other   causes    (page   989),. 
may  cause  very  troublesome  dysmenorrhea. 

11.  Reflex  Dysmenorrhea.  There  are  occasional  cases  of  dysmenorrhea 
apparently  due  to  reflex  disturbance  from  a  distant  part  of  the  body.  One  of 
the  most  striking  of  such  reflex  connnections  is  that  from  within  the  nose. 
In  certain  cases,  dysmenorrhea  has  apparently  been  due  to  some  pathologic 
intranasal  condition  and  has  been  relieved  by  treatment  of  the  same.  These 
are  sometimes  referred  to  as  cases  of  "nasal  dysmenorrhea."  In  certain 
other  cases,  menstrual  pain  has  been  relieved  by  cocainization  of  particular 
areas  of  the  normal  nasal  mucosa.  This  fact  was  first  brought  to  the  attention 
of  the  profession  by  Fliess,  a  German  rhinologist,  who  in  1897  presented  to 
the  Berlin  Obstetric  Society  a  paper  detailing  his  experiments  in  that  direc- 
tion. He  found  that  in  some  cases  of  dysmenorrhea  the  pain  disappeared 
within  a  few  minutes  after  the  application  of  a  20  per  cent  cocaine  solution 
to  certain  areas  in  the  nose.  These  areas  were  the  anterior  end  of  the  inferior 
turbinated  bone  of  each  side,  and  a  spot  just  opposite  this  on  the  septum,  some- 
times referred  to  as  the  tuberculum  of  the  septum. 

Fliess  in  his  experiments  divided  the  cases  of  dysmenorrhea  which  he 
encountered  into  two  classes— first,  those  in  which  the  pain  ceased  as  soon 
as  the  menstrual  flow  began,  and,  second,  those  in  which  the  pain  continued 
along  with  the  flow.  In  the  first  class  he  noticed  no  particular  effect  from 
the  intranasal  cocaine  application.  In  the  second  class,  those  in  which  the 
pain  continued  during  the  flow,  the  effect  of  the  application  of  cocaine  to 
the  areas  mentioned  was  striking.  Usually  wdthin  five  to  seven  minutes  after 
the  application  the  pain  ceased,  and  did  not  reappear  during  that  menstrua- 
tion. In  some  cases  there  was  a  pathologic  condition  involving  the  areas 
mentioned,  but  the  same  result  was  obtained  in  many  cases  in  which  no  dis- 
ease was  apparent.  To  eliminate  ''suggestion"  as  a  factor  in  the  case,  the 
application  of  cocaine  was  made  to  other  intranasal  areas,  instead  of  to  those 
mentioned,  and  there  was  no  result.  Again,  the  designated  areas,  which  are 
sometimes  referred  to  as  the  ''genital  spots,"  were  touched  with  an  inert 
solution  and  there  was  no  result.  Again,  in  those  cases  in  which  temporary 
relief  followed  the  application  of  cocaine  to  the  intranasal  genital  spots, 
cauterization  of  those  areas  produced  a  cure,  either  permanent  or  lasting 
several  months. 

Good  results  have  since  been  obtained  by  other  reliable  observers  in  various 
parts  of  the  world  and  this  measure  has  been  established  as  useful  in  the 
treatment  of  certain  cases  of  dysmenorrhea.  It  has  also  served  to  call  atten- 
tion to  the  fact  that  certain  pathologic  conditions  in  the  nose  may  give 
rise  "to  troublesome  dysmenorrhea,  and  hence  in  a  case  of  dysmenorrhea  that 
persists  without  apparent  cause  a  careful  rhinologie  examination  should  be 
made  to  exclude  nasal  trouble  or  to  discover  and  remove  it. 

12.  Neurasthenia.  The  neurasthenic  individual  is  prone  to  pains  in  the 
pelvis,  as  in  other  parts  of  the  body,  and,  of  course,  they  are  likely  to  be 


1002  DISTURBANCES    OF   FUNCTION 

most  severe  at  the  menstrual  time.  These  pelvic  pains  occur  without  any- 
apparent  local  cause.  The  cases  usually  present  the  characteristic  of  "neuralgic 
dysmenorrhea."  Such  patients  are  often  subjected  to  ine:ffectual  treatment 
for  many  months— until  the  practitioner  grasps  the  fact  that  he  is  dealing, 
not  with  a  local  condition,  but  with  a  widespread  affection  of  the  nervous 
system. 

13.  Hysteria.  In  patients  with  hysteria  the  disturbances  may  be  much 
increased  at  the  menstrual  time.  In  some  cases  the  hysteric  manifestations 
between  the  periods  are  so  slight  that  hysteria  is  not  suspected  until  a  careful 
examination  is  made. 

Treatment  of  Dysmenorrhea  in  the  Virgin 

In  a  case  of  dysmenorrhea  in  a  virgin  a  local  examination  is  not  called 
for  at  first,  unless  the  patient  has  taken  a  course  of  treatment  without  decided 
benefit  or  there  are  symptoms  indicating  some  decided  local  lesion.  If  there 
are  no  symptoms  between  the  menses,  indicating  some  gross  lesion,  it  is  to 
be  assumed  that  the  menstrual  pain  is  due  to  that  most  frequent  cause — 
defective  nutrition  with  uterine  hyperesthesia,  anteflexion  of  cervix  and 
more  or  less  stenosis  of  the  cervical  canal.  This  condition  may,  for  con- 
venience, be  designated  as  ''neurotrophic"  dysmenorrhea  (page  996).  The 
management  of  the  cases  may  be  conveniently  divided  into  two  parts — (A) 
treatment  during  the  menstrual  flow  and  (B)  treatment  between  the  periods. 

(A)  Treatment  During  the  Flow 

Suppose  you  are  called  to  see  the  patient  while  she  is  menstruating  and 
in  much  pain.    The  flrst  thing  to  do  is  to  relieve  her  immediate  suffering. 

1.  General  Measures.  Put  the  patient  to  bed  and  have  hot  stupes  applied 
to  the  lower  abdomen,  and  the  bowels  freely  opened  by  an  enema  or  a  purga- 
tive or  by  both.  In  some  cases  you  will  find  that  the  patient  has  already  car- 
ried out  this  part  of  the  program  and.  has  also  taken  hot  drinks  of  various 
kinds,  having  found  by  experience  that  these  measures  diminish  the  pain. 

2.  Sedatives  Internally.  For  further  relief,  if  the  pain  is  troublesome  in 
spite  of  the  above  measures,  give  some  sedative.  The  time-honored  viburnum 
prunifolium  Avill  often  give  considerable  relief.  It  may  be  given  either  as 
the  plain  fluid  extract  or  in  the  form  of  one  of  the  less  nauseating  and  more 
effective  preparations  supplied  by  reliable  manufacturing  drug  houses — for 
example,  Liquor  Sedans  (P.  D.  &  Co.),  which  contains  4  gr.  of  viburnum,  8  gr. 
of  hydrastis,  4  gr.  of  Jamaica  dogwood  and  5  gr.  of  cascara  to  each  teaspoon- 
ful.  If  the  pain  is  severe,  this  is  not  sufficient  for  immediate  relief.  For  the 
severe  pain  prescribe  phenacetin  and  codeine.  There  are  a  number  of  other 
preparations  that  are  sometimes  used  Avith  benefit,  among  them  camphor,  fluid 
extract  of  cimicifuga  and  aromatic  spirits  of  ammonia.  In  those  cases  in 
which  nervousness   is   a  prominent   feature,   give  sodium   bromide   in   10   gr. 


DYSMENORRHEA  1003 

to  20  gr.  doses  every  three  hours  -until  the  general  nervous  irritability 
subsides. 

Morphine  is  rarely  necessary.  When  the  pain  can  not  be  otherwise  relieved, 
morphine  may  be  given  for  temporary  relief,  but  it  should  be  given  in  such  a 
way  that  the  patient  does  not  know  what  she  is  taking.  The  above  measures 
usually  give  the  patient  relief,  but  she  should  stay  in  bed  as  long  as  there  is 
any  tendency  of  the  pain  to  be  severe. 

3.  Intranasal  Applications.  This  may  be  tried  in  those  cases  in  which  the 
pain  persists  after  the  flow  is  well  established.  Schiff  found  this  treatment 
effective  in  35  out  of  41  cases  in  which  it  was  tried.  Ephraim  reported  18 
successes  in  24  cases,  and  Linder  10  successes  in  16  cases.  It  has  proved  suc- 
cessful in  some  cases  that  persisted  in  spite  of  dilatation  and  curetment  and 
various  kinds  of  internal  medication.  On  the  other  hand,  it  has  failed  com- 
pletely in  cases  that  apparently  should  have  been  relieved  by  it.  It  is  uncer- 
tain, but  is  worthy  of  trial  in  selected  cases.  When  using  this  treatment 
remember  the  following  points  : 

a.  The  application  is  made  in  each  nostril,  to  the  region  including  the 
anterior  end  of  the  inferior  turbinated  bone  and  the  adjacent  portion  of  the 
septum. 

b.  The  strength  of  the  cocaine  solution  usually  used  is  20  per  cent  though 
possibly  a  weaker  solution  (e.  g.,  10  per  cent)  w^ould  do. 

c.  The  application  should  be  made  by  the  physician  only,  and  the  patient 
should  not,  as  a  rule,  know  what  is  being  applied.  The  solution  should  not  be 
given  to  the  patient  for  use  at  home,  as  it  might  lead  to  the  formation  of  the 
cocaine  habit. 

d.  In  those  cases  in  which  the  cocaine  application  stops  the  pain,  the  ''gen- 
ital areas"  in  the  nose  should  be  cauterized  by  a  rhinologist,  that  the  reflex 
feature  of  the  dysmenorrhea  may  be  cured  or  relieved  for  some  months. 

(B)  Treatment  Between  the  Menstrual  Periods 

After  the  pain  is  relieved  for  that  menstrual  period,  then  comes  the  ques- 
tion of  treatment  in  the  interval,  to  prevent  or  diminish  the  pain  of  succeeding 
periods. 

In  the  virgin  a  local  examination  is  not  called  for  at  flrst  in  the  absence 
of  decided  local  symptoms  between  the  menstrual  periods.  The  first  thing  to 
do  is  to  put  the  patient  on  a  regimen  of  general  measures  and  internal  treat- 
ment that  will  put  her  in  first-class  general  health. 

1.  General  Measures.  The  general  measures  are  directed  toward  improv- 
ing the  general  muscular  tone,  correcting  anemia  and  overcoming  constipa- 
tion. They  have  ben  given  in  detail  when  speaking  of  the  treatment  of 
amenorrhea  (page  979). 

2.  Internal  Treatment.  The  patient  is  placed  on  some  good  iron  tonic, 
with  or  without  the  addition  of  arsenic  or  strychnine  or  quinine,  as  thought 


1004  DISTURBANCES    OF    FUNCTION 

best.  She  is  given  also  siicli  other  medicines  as  are  indicated  by  special 
symptoms  present — e.  g.,  by  indigestion  or  cough,  or  sleeplessness  or  neural- 
gias. Remember  that  in  gouty  or  rheumatic  patients,  dysmenorrhea  is  some- 
times much  relieved  by  remedies  directed  towards  overcoming  the  nutritiona-' 
disorder  manifested  by  the  gout  or  rheumatism.  Laxatives  also  are  importan " 
when  there  is  any  tendency  to  constipation.  Give  some  tonic  laxative  i^ 
sufficient  doses  to  give  one  or  two  good  bowel  movements  daily. 

Some  antispasmodics  have  a  particular  effect  in  overcoming  menstrual 
pain.  Decided  benefit  is  often  secured  by  the  viburnum  preparations  pre- 
viously mentioned,  given  in  moderate  doses,  three  times  daily-  continuously 
and  increased  to  every  four  or  six  hours  during  the  flow.  If  there  is  excesdve 
flow,  ergotin  with  cannabis  indica  in  capsules  may  be  used.  These  are  admis^iis- 
tered  continuously  for  some  months.  The  other  preparations  used  especiaily 
for  excessive  menstruation,  stypticin  and  styptol,  have  a  tendency  also  tO' 
diminish  the  menstrual  pain.  Two-drop  doses  of  tincture  of  Pulsatilla,  give  v 
three  times  daily  for  several  days  before  the  flow,  occasionally  cu/e.-t 
dysmenorrhea.  '  t  ' 

Many  other  preparations  belonging  to  the  general  class  of  antispasmodic;^' 
and  mentioned  in  works  on  materia  medica  and  therapeutics,  have  been  usdi 
from  time  to  time  for  dysmenorrhea — with  marked  relief  to  some  patiefit"? 
and  with  no  relief  to  others.  As  a  general  proposition,  those  remedies  whie*. 
are  beneficial  in  neuralgias  are  beneficial  also  in  dysmenorrhea.  Thyroi"?^ 
extract  has  been  used  with  benefit  in  some  series  of  cases — one  series  showing- ■ 
marked  benefit  in  80  per  cent  of  the  cases.  ^'- 

3.  Intranasal  Examination.  In  cases  where  there  are  any  nasal  symptomsv 
and  also  in  the  cases  relieved  by  intranasal  applications,  rhinologic  examina- 
tion should  be  made.  If  some  nasal  disease  is  present,  the  removal  ^of  it 
may  so  improve  the  menstrual  pain  that  the  patient  is  saved  much  suffering 
and  is  spared  the  embarrassment  of  a  pelvic  examination. 

4.  Pelvic  Examination  to  determine  local  lesion.  If  there  is  no  decided: 
benefit  from  the  measures  already  mentioned  after  two  or  three  menstrual 
periods,  or  at  any  time  if  severe  local  symptoms  develop,  the  patient  should 
be  examined  to  determine  if  there  is  any  local  lesion.  The  details  of  the- 
examination  of  a  virgin  have  been  given  (page  108).  In  many  cases  it  it 
best  to  make  the  examination  under  anesthesia,  for  the  reasons  there  stated.. 
When  examining  a  patient  under  anesthesia  for  dysmenorrhea  or  for  nienor- 
rhagia,  preparation  should  be  made  for  dilatation  and  curetment,  so  thuse 
therapeutic  measures  could  be  at  once  carried  out  under  the  examination- 
anesthesia  should  the  examination  reveal  a  condition  requiring  it.  Also,  if  a 
retrodisplacement  is  found,  an  attempt  to  correct  it  by  manipulation  may  b& 
mad©  carefully  while  the  patient  is  under  the  anesthetic. 

The  subsequent  treatment  will  depend,  of  course,  upon  the  conditions  found 
on  examination.  If  there  is  backward  displacement  of  the  uterus,  treatment 
for  that  is  required  (page  678) ;  if  there  is  a  fibroid  tumor  of  the  uterus,  the 


DYSMENORRHEA  1005 

treatment  is  for  that  (page  727) ;  if  there  is  pelvic  tuberculosis,  the  treatment 

s  for  that,  as  indicated;  if  the  trouble  is  neurotrophic  dysmenorrhea,  that 

'  aist  receive  the  proper  attention,  and  so  down  the  list  of  possible  conditions. 

;:he  treatment  for  these  various  conditions  Avill  be  found  in  the  appropriate 

'  hapters. 

The  condition  styled  neurotrophic  dysmenorrhea  belongs  especially  to 
this  chapter.  The  local  measures  of  treatment  for  this  condition  are,  in  gen- 
oral,  measures  directed  toward  overcoming  the  stenosis  and  removing  an 
unhealthy  endometrium,  with  such  nutritional  change  as  would  necessarily 
f olloAv  this  instrumentation.  These  measures  will  be  mentioned  as  a  continua- 
ticr.  of  the  treatment  of  the  dysmenorrhea  in  cases  where  no  more  marked  local 
lesion  is  found. 

•  5.  Thorough  Dilatation  and  Curetment  under  Anesthesia.  As  previously 
explained,  this  should  as  a  rule  be  the  first  local  measure  employed  in  the 
Viirgin,  as  it  is  not  advisable  to  employ  any  local  treatment  unless  it  is  of 
»ueh  character  that  it  will  have  some  decided  effect.  If  the  patient  is  to  be 
iinesthetized  for  examination,  preparation  should  be  made  so  that  dilata- 
X.-'-li  and  curetment  could  be  carried  out  at  the  same  time  if  found  advisable. 
T'  ^  curetment  is  important,  for  it  enhances  the  nutritive  effect  of  the  dilatation 
—  ^nd  the  benefit  from  the  procedure  is  due  to  its  nutritive  effect  on  the  uterine 
.  ssues  as  well  as  to  the  removal  of  obstruction.  The  details  of  this  operation 
Ave  been  given  (pages  644  to  657). 

If  the  patient  is  engaged  to  be  married  soon,  the  examination  under  anes- 
xl.esia  with  the  dilatation  and  curetment  should  not  ordinarily  be  carried 
<'Ut.  Wait  until  several  months  after  marriage  before  employing  any  local 
measures.  In  the  meantime  pregnancy  may  take  place,  and  that  will  do  more 
toward  a  permanent  cure  of  the  trouble  than  the  most  radical  operative 
measure.  The  marked  effect  of  pregnancy  in  these  cases  of  neurotrophic 
dysmenorrhea  is  an  additional  indication  that  it  is  largely  a  nutritional 
..rouble:  Pregnancy  exercises  a  most  profound  influence  upon  the  nutrition 
of  the  uterus,  both  of  the  muscular  tissue  and  of  the  mucosa.  It  has  been 
argued  that  pregnancy  and  parturition  produce  the  marked  curative  effect 
in  these  cases  by  overcoming  the  stenosis.  Without  doubt  it  does  overcome 
the  stenosis  better  than  any  other  known  measure,  but,  as  has  already  been 
explained,  the  stenosis  is  only  one  feature  of  the  trouble  and  the  removal 
of  the  stenosis  alone  does  not  always  effect  a  cure. 

.  We  may  confidently  expect  considerable  relief  from  thorough  dilatation 
and  curetment  in  the  great  majority  of  the  cases.  The  duration  of  the  improve- 
ment is  variable.  In  a  majority  of  the  cases  there  is  a  return  of  the  trouble 
after  periods  varying  from  a  few  months  to  several  years,  though  it  usually 
does  not  become  so  severe  as  it  formerly  was.    In  95  cases,  reported  by  Kelly, 

32  were  relieved  (19  completely  and  14  largely),  with  no  return  of  the  trouble 

the  period  of  observation  extending  from  one  to  twelve  years;  in  7  cases 
there  was  relief  for  a  period  varying  from  one  to  nine  years,  the  dysmenor- 


1006  DISTURBANCES    OF   FUNCTION 

rhea  finally  returning ;  in  28  cases  there  was  relief  for  a  few  months,  bnt  the 
dysmenorrhea  returned  within  a  year;  and  in  the  remaining  28  cases  there 
was  no  relief. 

With  the  dilatation  and  curetment  in  these  cases,  it  is  well  to  pack 
the  dilated  cervix  firmly  with  gauze  and  leave  the  packing  in  place  for  forty- 
eight  hours,  so  as  to  hold  the  internal  os  well  open  until  the  reparative 
infiltration  begins,  in  order  that  the  dilatation  may  be  made  as  prolonged  as 
possible.  Along  with  this  local  treatment  and  following  it,  the  various  gen- 
eral measures  previously  recommended  should  be  used. 

In  order  to  make  the  dilatation  more  lasting  Frye  advocated  the  imme- 
diate use  of  a  hard  rubber  drainage  plug  or  intrauterine  stem.  He  states 
that  immediately  following  the  dilatation  and  curetment,  "a  Wylie  drainage 
plug,  as  large  as  will  readily  pass,  is  inserted  into  the  cervical  canal  and  held 
in  position  by  a  Smith  pessary.  For  a  number  of  years  I  was  accustomed 
to  leave  the  plug  in  place  for  six  days,  but  following  the  suggestion  of  Dr. 
Wylie  I  now  allow  it  to  remain  from  three  to  six  Aveeks  and  the  result 
is  better.  I  usually  keep  the  patient  in  bed  two  or  three  weeks  after 
operation,  and,  if  no  discomfort  be  experienced,  permit  her  to  get  up  and  go 
around,  wearing  the  plug  several  weeks  longer.  I  believe  the  use  of  the  hard 
rubber  drainage  plug  does  much  to  add  to  the  permanency  of  the  relief 
obtained.  When  retained  sufficiently  long,  it  causes  the  formation  of  a  cica- 
tricial ring  of  tissue  at  the  point  of  constriction,  which  insures  patulency.  I 
have  not  seen  any  bad  results  follow  its  use.  In  a  few  cases  it  causes  pain, 
and  on  that  account  must  be  removed  sooner  than  the  specified  time."  It 
must  be  kept  in  mind,  however,  that  when  we  leave  a  foreign  body  in  the 
uterus  for  several  days,  particularly  immediately  after  opening  up  the  lymph 
spaces  by  curetment,  we  take  great  risk  of  causing  inflammatory  trouble, 
which  may  extend  to  tubes  and  become  far  more  serious  than  the  menstrual 
pain.    In  exceptional  cases  one  may  be  justified  in  taking  this  risk. 

The  cases  which  are  particularly  amenable  to  dilatation  are,  of  course, 
those  in  which  the  obstructive  feature  is  prominent ;  i,  e.,  the  pain  is  severe 
and  cramp-like,  is  most  severe  just  as  the  flow  is  starting  and  largely  disap- 
pears when  the  flow  is  well  established.  When  there  is  a  tendency  to  later 
return  of  the  obstructive  features  of  the  dysmenorrhea,  then  is  the  time  for 
the  use  of  partial  dilatation  or  electricity — or  stem  pessary  in  suitable  cases. 

6.  Partial  Dilatation  of  the  Cei^vical  Canal  in  the  Office.  This  is  rarely 
advisable  in  the  virgin  for  the  reason  that  in  such  a  patient  it  is  difficult,  pain- 
ful, ineffective  and  subjects  the  girl  to  a  pelvic  examination  without  much 
chance  of  benefit.  As  a  rule,  when  the  measures  previously  mentioned  fail, 
it  is  better  to  give  the  patient  an  anesthetic  and  dilate  thoroughly  and  curet 
as  above  explained.  Occasionally,  however,  in  an  unmarried  woman  this  par- 
tial dilatation  is  practicable  and  gives  much  relief. 

The  patient  is  placed  in  the  Sims  posture,  the  Sims  speculum  introduced, 
the  cervix  caught  and  brought  into  view,  and,  with  the  antiseptic  precau- 


DYSMENORRHEA 


1007 


tions  necessary  in  all  intrauterine  work,  the  graduated  metal  dilators  are  intro- 
duced into  the  cervical  canal  and  past  the  internal  os — beginning  with  the 
smallest  size  that  the  canal  AA'ill  accommodate  and  passing  to  the  largest.  After 
dilatation  the  vagina  is  again  cleansed  with  the  antiseptic  solution,  the  speculum 
removed  and  the  patient  directed  to  lie  down  for  a  time  after  she  gets  home 
and  to  be  rather  quiet  the  remainder  of  the  day.  This  dilatation  is  made  each 
month  just  before  the  menstrual  time.  It  is  well  to  dilate  four  or  five  days 
before  the  flow  is  expected  and  then  again  the  day  before  the  flow.  The  closer 
the  dilatation  to  the  beginning  of  the  flow,  the  better  the  effect,  but,  if  one 
waits  until  the  day  before  the  expected  flow  for  the  first  dilatation,  the  flow 
may  come  a  day  or  two  too  soon,  and  thus  the  dilatation  is  missed  entirely. 

7.  Stem  Pessary  or  Wire  Spring".    Like  partial  dilatation,  this  is  not  appli- 


Fig.  78S.     Stem  Pessaries:  a,   Outerbridge's  cervical  spring;   h,  hard-rubber  stem  pessary;    c,  aluminum 

stem   pessary. 

cable  in  most  cases  of  dysmenorrhea  in  the  virgin  until  after  the  cervix  has 
once  been  thoroughly  dilated  under  anesthesia. 

In  the  exceptional  cases  in  which  partial  dilatation  is  practicable  and 
effective  temporarily,  but  must  be  repeated  every  month,  the  stem  pessary  or 
the  ^Tiv^  spring  may  be  used  to  maintain  the  dilatation.  The  use  of  the  stem 
pessary  must  be  attended  with  great  caution.  It  was  formerly  used  fre- 
quently and  led  to  serious  pelvic  inflammatory  trouble  in  many  cases.  The 
harmful  results  were  so  frequent  that  the  use  of  the  stem  pessary  Avas  prac- 


1008  DISTURBANCES    OF   FUNCTIOiST 

tieally  dropped  by  careful  workers.  Later  it  was  found  that  in  certain  excep- 
tional cases  nothing  would  take  its  place,  and  that  in  these  carefully  selected 
cases  and  under  proper  technic  it  could  be  used  with  comparatively  little  risk. 

Its  field  of  usefulness  is  to  overcome  the  obstruction  or  stenosis  in  those 
cases  without  other  pelvic  lesion  and  in  which  this  feature  causes  much  suf- 
fering in  spite  of  the  employment  of  less  undesirable  measures.  As  was  well 
emphasized  by  Carstens,  who  has  done  much  to  popularize  the  proper  use 
of  the  stem  pessary,  it  must  never  be  used  in  a  case  where  there  has  been 
any  tubal  or  ovarian  or  other  form  of  periuterine  inflammation,  or  when 
there  are  adhesions.  This  is  very  important,  for  the  use  of  a  stem  pessary  in 
such  cases  may  lead  to  serious  results.  Active  inflammation  in  the  uterus 
should  also  be  excluded.  The  use  of  the  stem  pessary  in  the  virgin  has  also 
the  same  objections  that  hold  for  partial  dilatation  or  any  other  local  treat- 
ment. Its  use  should  as  a  rule  be  reserved  for  those  cases  in  which  the  severe 
pain  returns  after  thorough  dilatation  and  curetment  under  anesthesia.  In 
the  married  woman,  where  the  objection  to  local  treatment  is  not  present 
and  where  also  the  cervix  is  likely  to  be  softer  and  more  easily  dilatable,  it  is 
more  frequently  advisable,  along  with  partial  dilatation,  as  a  treatment  pre- 
ceding thorough  dilatation  under  anesthesia.  The  cases,  however,  must  be 
carefully  selected,  as  previously  pointed  out.  A  foreign  body  remaining  in 
the  uterus  for  weeks  at  a  time  is  a  hazardous  condition,  and  such  treatment 
should  be  employed  only  with  a  definite  understanding  of  the  indications 
and  contraindications,  and  then  only  in  cases  when  the  advisability  of  this 
treatment  rather  than  some  other  is  clearly  established. 

It  must  be  kept  in  mind  also  that  other  therapeutic  measures  must  also  be 
used,  as  indicated  by  the  conditions  present.  The  established  effect  of  the  stem 
pessary  is  simply  to  overcome  the  stenosis — though  it  is  possible  that  it  has 
some  stimulating  effect  on  the  local  nutrition  and  on  the  muscular  develop- 
ment  (Carstens). 

The  pessary  is  applied  after  partial  dilatation  (page  1006)  and  under  the 
same  strict  antiseptic  precautions  used  in  sounding  the  uterus  (page  123). 
The  preferable  time  to  apply  it  is  a  few  days  before  the  menstrual  flow.  If 
the  menstrual  pain  for  that  period  is  relieved,  the  pessary  may  be  left  in 
place  continuously  for  some  months,  providing  no  symptoms  of  irritation 
appear.  The  patient  should  take  a  mild  antiseptic  douche  every  day  or  two  to 
prevent  the  possible  growth  of  germs  in  the  vagina  that  might  ascend  along 
the  open  cervical  canal.  The  intrauterine  stem  should  always  have  openings 
or  grooves  along  which  the  uterine  secretion  may  freely  escape.  Useful 
forms  are  shown  (Fig.  785).  Outerbridge's  intracervical  spring  tends  to  hold 
open  the  canal  without  occupying  much  of  the  lumen.  Goelet,  also,  advo- 
cates the  use  of  the  intrauterine  stem  pessaries  and  illustrates  a  glass  stem 
with  a  hollow  center  and  a  flange  at  the  bottom,  to  be  held  in  place  by 
vaginal  gauze  packing.    He  states  that  "it  is  never  kept  in  the  uterus,  how- 


DYSMENORRHEA  '  1009 

ever,  for  a  longer  period  than  one  week,  and  during  that  time  the  patient  is 
confined  to  bed." 

8.  Electricity.  Intrauterine  applications  of  electricity  may  give  consider- 
able relief  in  cases  where  the  trouble  returns  after  the  cervical  canal  has  been 
once  thoroughly  dilated. 

The  application  of  electricity  may  be  carried  out  along  with  the  partial 
dilatation  just  before  menstrual  periods,  the  electrode  being  used  to  effect 
the  dilatation  of  the  cervix.  With  the  galvanic  current,  use  the  negative  pole 
in  the  uterus,  under  the  antiseptic  precautions  necessary  in  all  intrauterine 
treatment.  The  electrode  may  be  used  to  dilate  the  canal.  Introduce  the 
small  size  electrode  (page  399)  as  far  as  it  will  pass  easily  and  then  turn  on 
the  current,  making  the  internal  electrode  the  negative  pole.  Use  a  weak 
current,  about  10  to  15  milliamperes.  Make  a  steady  gentle  pressure  on  the 
electrode,  and  as  the  tissues  relax  about  the  electrode  it  passes  further  and 
further  along  the  canal  until  it  extends  past  the  internal  os.  Then  use  the 
larger  sizes  until  the  cervix  is  well  dilated.  Then  an  intrauterine  applica- 
tion of  the  electricity  is  made,  using  15  to  20  m.a.  at  first  and  continuing 
the  application  five  to  ten  minutes.  The  applications  are  given  once  or  twice 
Aveekly.  If  no  result  is  observed  from  this,  the  strength  is  increased  to  30 
or  40  or  50  m.a.  If  there  is  a  tendency  to  menorrhagia  as  well  as  dysmenor- 
rhea, it  is  well  to  follow  the  employment  of  the  negative  pole  with  the 
employment  of  the  positive  pole  for  5  to  10  minutes.  In  cases  that  do  not  do 
well  under  the  negative  pole,  it  is  well  to  employ  the  positive  pole  altogether. 
Some  cases  do  better  under  the  faradic  current,  and  when  one  method  does 
not  suffice  the  various  other  methods  may  be  tried. 

Electricity  has,  of  course,  the  dangers  and  contraindications  common  to 
other  forms  of  intrauterine  treatment.  It  has  an  admirable  effect  in  some 
cases,  while  in  other  eases  there  is  apparently  no  effect.  It  has  given  relief 
in  many  obstinate  cases,  and  is  worthy  of  trial  in  those  cases  where  there  is 
no  objection  to  vaginal  and  intrauterine  instrumentation.  It  is  useful  also  in 
certain  cases  of  that  most  obstinate  form  of  menstrual  pain — viz.,  mem- 
branous dysmenorrhea.  Dunning  relates  a  case  which  persisted  in  spite  of 
a  course  of  local  applications,  divulsion  and  curetment,  abdominal  section  with 
breaking  of  adhesions,  and  excision  of  a  diseased  ovary  and  ventro-suspension, 
but  finally  yielded  to  intrauterine  applications  of  electricity — 20  to  50  ma. 
negative  pole  for  five  minutes,  and  the  current  slowly  turned  off  and  then 
on  again  with  positive  pole  for  five  minutes.  This  was  repeated  twice  weekly. 
The  first  menstruation  after  the  applications  showed  less  pain.  At  the 
second;-  the  membrane,  which  before  had  been  a  cast,  was  reduced  to  shreds. 
After  the  third  menstruation  no  membrane  passed.  The  report  was  made 
four  months  later,  at  which  time  there  had  been  no  return  of  the  trouble,  which 
before  had  been  so  severe  and  persistent  in  spite  of  all  measures  that  the 
patient  meditated  suicide.  Thie  electricity  was  continued  tAvo  or  three  times 
monthly  as  a  preventive  against  recurrence.    In  the  discussion,  L.  R.  Brown  re- 


1010 


DISTURBANCES    OF   FUNCTION 


ported  a  case  of  membranous  dysmenorrhea  wliieli  resisted  repeated  thorough 
dilatation  and  curetment,  and  the  patient's  suffering  was  so  severe  that  she  was  a 
nervous  wreck.  As  a  last  resort  he  used  electricity — galvanic  current,  positive 
pole  in  the  uterus,  12  ma.  continued  for  eight  minutes,  and  repeated  three 
times  per  week.  At  the  first  menstrual  flow  there  was  no  improvement.  At 
the  second  menstruation  she  passed  no  membrane,  and  after  that  the  improve- 
men  was  continuous,  with  no  relapse  during  the  several  months  the  patient 
was  under  observation.  The  menstrual  flow,  which  formerly  lasted  ten  days, 
was  reduced  to  four  (effect  of  the  positive  pole). 

In  regard  to  choice  of  pole,  remember  that  the  positive  pole  has  a  con- 
stricting effect,  diminishes  congestion,  dries  the  tissues  about  the  electrode, 
and  hence  causes  the  electrode  to  stick  where  it  is.  It  is  not  suitable  for 
dilating  a  canal.  Before  using  the  positive  pole  the  electrode  should  be  carried 
all  the  way  into  the  uterine  cavity.  The  negative  pole,  on  the  other  hand, 
increases  congestion,  softens  the  tissues  and  aids  in  dilating  the  canal  (see 
also  pages  402  and  403). 

9.  Excision  of  Tissue  from  Internal  Os.  (Theilhaber  Operation.)  The  cer- 
vix is   dilated  thoroughly,    and   curetment   is   carried   out   if   desired.      The 


Fig.  786.  Splitting  the  Cervix  for  Dysmenorrhea  (Dudley  operation).  A,  showing  the  sharp  bend- 
ing of  the  canal  from  the  anteflexion  of  the  cervix;  B,  showing  the  unobstructed  exit  secured  by  split- 
ting the  posterior  lip  of  the  cervix  and  sewing  it  open. 


cervix  is  then  split  laterally,  and  each  side,  to  near  the  internal  os.  Then  with 
a  small  knife,  inserted  under  the  direction  of  the  finger-tip  carried  to  the 
internal  os,  as  a  small  wedge  of  tissue  is  removed  from  the  anterior  and  from 
the  posterior  portion  of  the  circulating  ring.  This  wedge  of  tissue  extends 
about  one-third  through  the  thickness  of  the  uterine  wall.  The  work  is  much 
facilitated  by  a  knife  of  special  design.  The  preliminary  incisions,  splitting 
the  cervix,  are  then  closed  by  sutures. 


DYSMENORRHEA 


1011 


This  removal  of  wedges  of  tissue  from  the  constructing  ring  at  the  inter- 
nal OS  enlarges  the  opening  and  overcomes  the  obstruction.  Series  of  cases 
have  been  reported  with  excellent  results  in  nearly  all  cases  as  far  as  relieving 
the  obstruction.  The  author  employed  the  operation  with  satisfaction,  but 
prefers  the  Dudley  operation,  which  gives  greater  probability  of  permanently 
overcoming  the  obstruction.  The  small  wedge-shaped  grooves  left  by  the 
excision  of  tissue  in  the  Theilhaber  operation  are  likely  to  fill  up  with  scar- 


Fig.  787.  Dudley  Operation.  Dividing  the  pos- 
terior wall  of  the  cervix.  (Dudley — Practice  of 
Gynecology.) 


Fig.  788.  Dudley  operation.  The  posterior  wall 
of  cervix  divided  and  the  principal  suture  passed. 
Before  passing  this  suture  a  wedge-shaped  piece  of 
tissue  is  excised  from  the  cervix  on  each  side  of 
the  wound,  as  indicated  by  the  dotted  lines.  (Dud- 
ley— Practice  of  Gynecology.) 


tissue  and  the  opening  again  become  small.    There  is  nothing  about  it  to  insure 
permanent  enlargement  of  the  opening. 

10.  Splitting  Cervix  and  Sewing  it  Open.  (Dudley  Operation — Fig.  786.) 
This  is  applicable  to  those  cases  of  anteflexion  of  the  cervix  in  which  the 
severe  menstrual  pain  persists  after  thorough  dilatation  and  curetment  under 
anesthesia.     In  some  cases  in  which  the  cervical  anteflexion  is  particularly 


1012  DISTURBANCES    OF   FUNCTION 

marked,  it  is  advisable  to  employ  tMs  as  the  primary  operative  procedure. 
The  steps  of  the  operation  are  as  follows  : 

a.  The  cervix  is  dilated  thoroughly  and  the  uterus  curetted  in  the  usual 
way. 

b.  The  posterior  lip  of  the  cervix  is  then  split  longitudinally  up  to  the 
vaginal  vault,  the  incision  being  carefully  continued  internally  up  to  and  past 
the  internal  os.  The  constricting  ring-  about  the  internal  os  should  he 
divided  sufficiently  to  readily  admit  a  finger.  Care  is  necessary  to  avoid  cut- 
ting too  deeply  into  the  uterine  wall  at  this  point,  for,  if  the  wall  is  cut 
through  and  the  peritoneal  cavity  opened,  there  is  danger  of  peritonitis. 
Ordinarily,  there  is  no  necessity  for  opening  the  peritoneal  cavity.  In  some 
eases,  however,  the  posterior  peritioneal  pouch  comes  very  low  or  the  inter- 
nal OS  is  situated  unusually  high.  In  either  case,  it  may  be  advisable  to 
deliberately  open  the  peritoneal  cul-de-sac  in  order  to  properly  complete  the 
operation.  The  division  of  the  intravaginal  portion  of  the  cervix  may  be  most 
conveniently  made  ^^dth  long  scissors  (Fig  787).  The  careful  division  of  the 
ring  about  the  internal  os  is  made  ^rith  a  bistoury  under  the  guidance  of  the 
finger. 

c.  A  wedge  of  tissue  is  then  cut  out  of  each  lip,  as  indicated  by  the  dotted 
lines  in  Fig  788,  so  that  each  of  the  two  cut  edges  will  fold  well  on  itself 
when  the  principal  suture  is  tied. 

d.  A  strong  silkworm-gut  suture  is  then  passed  as  shown  in  Fig.  788.  This, 
when  tied,  folds  the  cut  surface  of  each  lip  upon  itself  in  such  a  way  that 
the  ends  (Avhere  the  tenacula  are  caught  in  Fig.  788)  are  brought  into  the 
angle  of  the  wound,  and  this  tends  to  permanently  hold  apart  the  divided 
tissues  about  the  internal  os.  Before  this  main  suture  is  tied,  however,  sec- 
ondary sutures  of  catgut  should  be  passed  in  sufficient  numbers  to  close  the 
lateral  portions  of  the  wound  and  prevent  any  hemorrhage.  The  main  suture 
is  then  tied,  and  lastly  the  secondary  sutures.  It  is  important  to  pass  the 
sutures  deeply  enough  to  catch  the  bulk  of  the  divided  tissue  to  prevent  sul3- 
sequent  oozing.  In  one  of  the  author's  cases  persistent  oozing  followed  the 
operation  and  this  increased  after  several  hours  to  a  flow  of  blood,  which  firm 
vaginal  packing  failed  to  stop  and  which  affected  the  patient's  pulse,  and 
assumed  such  serious  proportions  that  he  was  called  to  the  hospital  in  the  mid- 
dle of  the  night.  He  placed  the  patient  in  Sims'  posture,  remoA^ed  all  the  pack- 
ing and  passed  two  or  three  strong  catgut  sutures  deeply  through  the  cer- 
vix in  such  a  way  as  to  effectually  constrict  all  the  tissue  from  which  the 
bleeding  might  come.  This  ^^'as  done  without  anesthesia  and  without  disturb- 
ing the  other  sutures.  This  stopped  the  bleeding  and  the  patient  convalesced 
Avithout  further  trouble. 

e.  In  cases  where  the  anterior  lip  of  the  cervix  is  very  long  it  may  be 
advisable  to  shorten  it  so  as  to  allow  the  cervix  to  better  assume  its  normal 
backward  direction,  instead  of  being  again  bent  forward  by  pressure  of  the 
•posterior  vaginal  Avail.     This  is  accomplished  by  excising  the  redundant  por- 


DYSMENORRHEA 


1013 


tion  of  the  anterior  lip  and  closing  tlie  resulting  raw  surface  by  sutures 
passed  transversely,  as  shown  in  Fig  789.  This  draws  a  good  wedge  of 
tissue  into  the  angle  between  the  cervix  and  corpus  uteri  and  tends  to  push 
the  cervix  back  toward  its  proper  direction. 

11.  Abdominal  Incision  of  Uterus.  This  method  (proposed  by  C.  W. 
Barrett)  consists  of  opening  the  abdomen  by  regular  suprapubic  incision, 
making  a  longitudinal  incision  through  the  posterior  wall  of  the  uterus  at 
the  internal  os,  spreading  this  incision  laterally  so  that  it  extends  trans- 
versely and  then  suturing  it  in  this  position.     It  accomplishes  enlargement  of 


Fig.  789.  Dudley  Operation.  The  operative  work  on  the  posterior  part  of  the  cervix  has  been  com- 
pleted. Also,  the  redundant  portion  of  the  anterior  lip  of  the  cervix  has  been  excised,  and  sutures  passed 
for  closing  the  wound.      (Dudley — Practice  of  Gynecology.) 

the  internal  os  and  consequent  relief  of  the  obstruction.  As  a  rule,  however, 
the  patient  may  be  sufficiently  relieved  without  subjecting  her  to  the  danger 
of  abdominal  section.  When  the  abdomen  must  be  opened  on  account  of 
accompanying  disease  of  the  adnexa  or  persistent  retrodisplacement  of  the 
uterus,  then  this  method  of  enlarging  the  internal  os  and  correcting  the  for- 
ward flexion  of  the  cervix  may  be  considered. 

12.  Operations  for  Diseased  Adnexa.  Of  course,  where  there  is  tubal  or 
ovarian  or  other  form  of  periuterine  disease,  that  should  receive  proper  treat- 


1014  DISTURBANCES   OF   FUNCTION 

meiit,  operative  or  otller^yise.  In  many  cases,  painful  menstruation  is  simply 
a  symptom  of  some  such,  pelvic  disease,  and  is  relieved  by  removal  of  tlie 
same.  In  membranous  dysmenorrhea,  also,  search  should  be  made  for  chronic 
ovarian  or  tubal  disease. 

The  remoA^al  of  practically  normal  ovaries  or  ovaries  that  are  not  seriously 
damaged,  for  the  relief  of  dysmenorrhea,  is  to  be  most  strongly  condemned. 
There  are  many  things  that  are  far  worse  than  some  pain  for  a  few  days  each 
month,  and  the  removal  of  both  ovaries  in  a  young  woman  is  one  of  them. 
Pain  may  be  relieved  temporarily  by  some  of  the  various  palliative  meas- 
ures already  described,  and  then  there  is  always  the  possibility  that  the  pain 
will  diminish  or  cease  from  the  lapse  of  the  tinie  and  the  continual  employment 
of  therapeutic  measures.  But  when  the  OA'aries  are  once  removed  they  are 
gone  irrevocably,  and  in  a  certain  proportion  of  such  cases  the  last  condition 
of  such  patient,  mentally  and  physically,  is  worse  than  death  itself.  Not  that 
the  removal  of  the  functionating  ovaries  in  a  young  woman  necessarily  or 
always  has  such  a  marked  mental  and  physical  effect,  but  in  certain  cases  it 
has,  and  we  can  never  be  certain  that  such  will  not  be  the  result  in  the  par- 
ticular case  under  consideration.  Of  course,  it  is  possible  that  there  may  be 
certain  rare  cases  in  which,  in  spite  of  every  other  measure,  the  patient's  suf- 
fering from  menstruation  is  such  as  to  justify  this  risk,  but  the  author  has  never 
met  such  a  case. 

(B)     DYSMENORRHEA  IN  THE  MARRIED  WOMAN 

Causes 

This  may  be  due  to  any  of  the  thirteen  conditions  described  as  causes  of 
dysmenorrhea  in  the  virgin,  on  pages  871  to  876.  It  may  be  due  also  to  one 
of  the  following  additional  conditions: 

14.  Infected  Endometritis,  acute  or  chronic. 

15.  Salpingitis  (acute  or  chronic)  or  one  of  the  other  forms  of  pelvic 
inflammation  (oophoritis,  pelvic  cellulitis,  pelvic  peritonitis). 

Judd  reported  217  cases  of  endometritis,  accompanied  Avith  more  or  less 
laceration  of  cervix  and  pelvic  floor,  of  which  108  suffered  menstrual  pain  and 
109  did  not.  He  reports  also  177  with  diseased  tubes  and  ovaries,  of  which  107 
had  menstrual  pain  and  70  did  not. 

In  married  women  membranous  dysmenorrhea  must  be  distinguished 
from  early  abortion  and  extrauterine  pregnancy,  in  both  of  which  condi- 
tions there  may  be  bloody  discharge,  with  much  pain  and  the  passage  of 
shreds  of  membrane.  If  this  happens  to  take  place  near  the  menstrual  time, 
the  patient  naturally  supposes  it  is  simply  a  menstruation  somewhat  delayed. 
In  membranous  dysmenorrhea  there  is  usually  a  history  of  the  expulsion 
of  membrane  at  several  menstrual  periods,  whereas  with  abortion  there  is 
the  history  of  a  missed  menstruation  and  of  morning  sickness.     Also  the 


INTERMENSTRUAL   PAIN  1015 

blood  clots  are  nmcli  more  numerous  in  abortion,  and  with  the  membrane 
can  usually  be  found  a  small  sac  and  embryo.  The  bleeding  from  abortion 
persists  indefinitely  until  the  uterus  is  emptied,  Avhereas  in  membranous  dys- 
menorrhea it  lasts  only  about  the  usual  menstrual  time.  Microscopic  examina- 
tion of  an  expelled  membrane  or  of  shreds  removed  by  curetment  in  abortion 
shows  chorionic  villi.  In  extrauterine  pregnancy  there  is  no  previous  history  of 
membranous  dysmenorrhea  and  the  patient,  previously  regular,  has  now  gone 
over  time  for  one  or  more  weeks.  The  pain  is  due  to  intraperitoneal  bleeding 
and  presents  the  characteristics  of  the  same. 

Treatment 

The  treatment  during  the  flow  is  the  same  as  detailed  for  the  virgin 
(page  1002).  The  treatment  in  the  interval  is  determined  by  the  local  trouble 
found  in  the  examination. 

INTERMENSTRUAL  PAIN 

The  interesting  subject  of  pain  occurring  at  a  certain  time  every  month 
in  the  intermenstrual  period  has  received  considerable  attention  from  investi- 
gators, and  the  conclusion  has  been  reached  that  it  is  not  an  indication  of  any 
particular  lesion.  Malcolm  Storer,  who  reported  20  cases  of  his  own  and  25 
additional  cases  collected  from  literature,  found  that  in  10  of  the  cases  there 
was  a  marked  increase  in  the  leucorrhea  at  that  time,  indicating  congestion  of 
the  uterus.  In  his  45  cases  reported  by  Storer  the  pain  appeared  with  regu- 
larity in  all  cases,  practically  every  month  unless  pregnancy  was  present.  In 
22  cases  it  appeared  always  at  the  same  time  (in  most  cases  about  two  weeks) 
after  the  beginning  of  last  menstrual  flow.  In  13  cases  there  was  a  varia- 
tion of  two  days,  in  four  cases  there  was  a  variation  of  four  days,  and  in  two 
cases  of  irregular  menstruation  it  would  appear  on  a  certain  day  before  the 
menstruation.  In  37  out  of  41  cases  the  pain  appeared  from  twelve  to  sixteen 
days  after  the  beginning  of  the  last  menstruation  and  in  20  of  them  it  began 
exactly  on  the  fourteenth  day.  In  2  cases  it  came  from  the  seventh  to  the  tenth 
days,  in  1  case  on  the  seventeenth  day  and  in  2  cases  on  the  eighteenth  day. 
Observations  like  these  well  support  the  view  now  generally  held  that  this 
periodically  returning  pain,  often  alternating  in  the  right  and  left  side  from 
mouth  to  month,  is  actually  caused  by  the  enlarged  Graafian  follicle  at  the 
time  of  ovulation.  The  investigations  of  Fraenkel  and  others  show  that  ap- 
proximately midway  between  menstruations  the  follicle  ruptures  and  the 
corpus  luteum  forms.  It  seems  plausible  that  under  certain  conditions  this 
process  might  be  associated  with  pain. 

Treatment  should  proceed  on  the  same  general  lines  as  the  treatment  laid 
do"\^-n  for  menstrual  pain;  i.  e.,  the  correction  of  general  conditions  first,  and 
the  employment  of  local  measures,  especially  of  operative  measures,  only  in 


1016  ■  DISTURBANCES    OF    FUNCTION 

cases  where  there  are  Avell-clefined  indications  and  after  other  measures  fail- 
As  Coe  has  pointed  out,  the  assumption  that  intermenstrual  pain  is  always 
associated  with  cystic  ovaries,  and  is  therefore  an  indication  for  operation, 
is  not  tenable.  Cystic  disease  of  one  or  both  ovaries  is  found  in  some  cases, 
Init  the  diagnosis  of  cystic  ovaries  or  an  operation  for  the  same  must  always 
be  based  on  distinct  examination  findings  (page  1004)  and  not  simply  on 
periodic  pain. . 

IRREGULAR  MENSTRUATION 

The  menstrual  flow  may  come  too  soon,  the  interval  being  only  ten  days 
or  two  weeks.  Again  the  flow  may  not  come  soon  enough,  running  overtime 
from  one  to  two  weeks.  It  is  sometimes  difficult  to  determine  positively 
whether  the  irregular  flow  complained  of  is  really  menstruation  or  simply  a 
bloody  discharge  from  some  disease  of  the  vagina  or  uterus.  Unless  the  bleed- 
ing resembles  closely  tlie  menstrual  flow  in  character  and  onset  and  duration, 
it  should  be  regarded  as  a  pathologic  discharge,  and  an  examination  should  be 
made  to  determine  its  cause,  that  proper  treatment  may  be  instituted. 

PRECOCIOUS  MENSTRUATION 

Precocious  menstruation  is  the  appearance  of  menstruation  at  an  early 
age.  For  genuine  menstruation  to  take  place,  there  must  be  considerable 
development  of  the  genital  organs,  and  this  very  rarely  occurs  before  the  age 
of  ten.  Eare  cases  have  been  recorded  in  all  ages,  even  in  infancy.  It  has  been 
known  to  begin  in  infancy  and  continue  regularly.  There  is  usually  precocious 
development  of  the  breasts  and  of  the  external  genitals.     (See  Chapter  xv.) 

Great  care  is  necessary,  however,  in  establishing  the  fact  of  precocious 
menstruation  in  a  given  case.  Every  stain  of  blood  does  not  mean  menstrua- 
tion. The  blood  may  come  from  some  inflamed  or  irritated  area  or  ulcer,  or 
growth  on  the  vulva  or  in  the  vagina,  uterus,  rectum  or  bladder.  In  infants 
a  slight  bloody  uterine  discharge  occurs  not  infrecpiently  within  the  first 
week  or  two  after  birth.  It  is  not  a  menstrual  flow  and  it  soon  disappears. 
Again,  a  red  stain  on  the  diaper,  which  the  mother  supposes  to  be  blood,  is 
often  made  by  urates  from  a  concentrated  urine.    • 

VICARIOUS  MENSTRUATION 

Vicarious  menstruation  is  the  discharge  of  blood  from  other  parts  of  the 
body  at  the  menstrual  time.  The  uterine  discharge  may  or  may  not  be  wholly 
or  partially  suppressed.  The  Ifleeding  usually  takes  place  from  the  nose  or 
from  some  open  sore,  though  it  may  come  from  almost  any  mucous  surface, 
such  as  the  lungs  or  stomach,  or  bladder  or  rectum.  Much  more  rarely  some 
area  of  the  cutaneous  surface  is  affected,  the  axilla  and  the  groin  being  the 
most  frequent.     At  the  affected  site  there  appears  an  ecchymosis  and  later  a 


DYSPAREUNIA  1017 

distinct  flow  of  bloody  serum.     The  vicarious  flow  is  lilvely  to  be  irregular, 
appearing   only  at   some   menstrual   periods.     Allied    closely   to   this   is   the 
.  monthly  discharge  of  milk  from  the  breasts  sometimes  observed.  ^ 

Vicarious  menstruation  in  any  form  is  rare.  Goffe  records  a  very  interest- 
ing case  in  which  the  vicarious  discharge  came  alternately  from  the  nose  and 
the  axilla,  and  seemed  to  be  associated  with  periods  of  ungratified  sexual  desire. 
Vicarious  menstruation  is  found  principally  in  nervous  women  in  whom  there 
is  imperfect  development  of  the  uterus  or  imperfect  performance  of  its  func- 
tions. The  treatment  consists  in  the  correction  of  any  pelvic  disease  present, 
and  in  applications  to  the  site  of  bleeding  if  necessary. 

DYSPAREUNIA 

The  two  principal  disturbances  of  sexual  intercourse  are  dyspareunia  (dif- 
ficulty in  coitus)  and  sexual  impotence  (absence  of  sexual  orgasm  in  coitus). 

Difficulty  in  coitus  (dyspareunia)  varies  from  a  slight  discomfort  hardly 
noticeable  to  pain  so  severe  as  to  make  coitus  unbearable. 

Causes 

The  more  common  causes  of  dyspareunia  are  as  follows: 
1.  Some  Obstruction  to  Normal  Coitus.  A.  Imperforate  hymen.  In  such  a 
case  there  would  be  present  the  history  of  amenorrhea  and  also  the  disturb- 
ances that  come  from  retained  menstrual  blood.  You  may  think  there  would 
be  a  history  of  no  coitus,  and  such  is  usually  the  case,  but  in  some  eases  coitus 
has  taken  place  through  some  adjacent  opening — for  example,  through  a 
dilated  urethra. 

B.  Organic  Stenosis  of  Vaginal  Orifice.  The  opening  is  large  enough  to 
permit  the  regular  escape  of  menstrual  blood,  but  it  is  not  large  enough  to 
permit  coitus.  The  obstructing  tissue  is  so  firm  that  it  does  not  rupture  as 
ordinarily  on  attempted  coitus.  This  obstruction  may  be  due  to  a  very  strong, 
firm  hymen,  or  to  some  distinct  malformation,  such  as  a  vaginal  septum  from 
double  vagina.  Usually  with  double  vagina,  each  vagina  is  large  enough  for 
coitus  or  the  septum  is  placed  so  far  to  one  side  that  it  does  not  interfere. 
But  it  may  be  so  placed  as  to  interfere  decidedly  with  coitus  and  to  require 
division.  Again,  an  organic  stenosis  here  may  be  due  to  scar-tissue  from  severe 
burn  or  other  injury,  or  from  laceration  in  labor,  with  extensive  scar-tissue 
formation. 

C.  Spasmodic  Stenosis  at  Vaginal  Orifice.  In  some  cases  there  is  marked 
hyperesthesia  about  the  vaginal  orifice,  and  every  attempt  at  coitus  causes 
unbearable  pain  or  causes  spasmodic  contraction  of  adjacent  muscles  to  such  ' 
an  extent  that  coitus  is  impossible.  This  marked  hyperesthesia  may  be  due  to 
inflammation,  such  as  vulvitis  or  vaginitis,  or  it  may  be  due  to  sensitive  abra- 
sions about  the  vaginal  entrance.    In  other  cases  it  is  due  to  that  peculiar  con- 


1018  DISTURBAXCES    OF   FUXCTIOX 

clitioii  known  as  "vaginismns,"  a  reflex  contraction  of  tlie  levator  ani  and 
adjacent  mnscles  without  apparent  cause.  In  exceptional  cases  this  is  so  severe 
and  persistent  as  to  prevent  coitus  altogether. 

D.  Severe  Pain  on  Attempted  Intercourse.  There  is  no  stenosis  or  spasm, 
but  just  pain,  so  severe  that  coitus  is  impossible.  This  may  be  due  to  inflam- 
mation about  the  external  genitals  or  inflammation  within  the  pelvis. 

2.  Simple  Inflamed  Abrasions  About  the  Vulva.  This  is  not  an  infrequent 
cause  of  much  suffering  immediately  after  marriage.  The  small  abrasions  that 
naturally  accompany  rupture  of  the  hymen  at  the  first  intercourse  may  become 
inflamed  after  a  day  or  two,  making  subsequent  coitus  painful.  This  some- 
times causes  much  alarm  to  the  patient  and  her  husband,  who  fear  some  serious 
trouble.  The  treatment  is  abstinence  from  coitus  for  a  few  days,  with  the 
frequent  use  of  some  mild  antiseptic  wash  (i/^  per  cent  carbolic  solution),  fol- 
lowed by  drying  with  absorbent  cotton  and  the  use  of  a  soothing  ointment, 
such  as  carbolized  vaseline.  It  is  well  to  keep  the  parts  covered  with  a  pad 
of  absorbent  cotton,  to  keep  the  clothing  from  contact  -^vith  the  painful  areas 
and  also  to  protect  the  abrasions  from  infection. 

3.  Venereal  Sores  (chancroid,  syphilitic).  These  ulcers  also  may  be 
found  soon  after  marriage  or  at  any  other  time.  Care  should  always  be  taken 
not  to  give  a  positive  prognosis  in  a  case  of  abrasion  or  sore  which  has  not  yet 
had  time  to  develop  its  characteristics. 

4.  Gonorrheal  Inflammation.  This  is  an  altogether  too  common  cause  of 
painful  coitus  in  the  first  few  weeks  following  marriage.  The  pain  may  be 
due  to  the  vulvar  inflammation,  or  to  the  urethritis  or  to  the  vaginitis,  or  to 
painful  abrasions  or  to  the  inflammation  of  the  A'ulvo-vaginal  gland  of  one  or 
both  sides. 

5.  Other  Forms  of  Inflammation  of  vulva  or  vagina,  or  vulvo-vaginal 
glands. 

6.  Inflammation  of  Uterus  (acute  or  subacute). 

7.  Inflammatory  Lesions  Around  the  Uterus,  in  which  pain  is  caused  by  the 
impact  of  the  male  organ  or  by  the  sexual  congestion.  When  the  ovary  is 
prolapsed  into  the  cul-de-sac  and  bound  there  by  adhesions,  sexual  intercourse 
may  cause  much  pain.  The  author  recalls  one  patient  in  whom  it  was  finally 
necessary  to  open  the  abdomen,  break  up  the  adhesions  and  fasten  up  the  pro- 
lapsed ovary  in  order  to  relieve  the  suffering  in  coitus.  In  the  more  serious 
pelvic  inflammatory  conditions,  this  is  frequently  a  prominent  sjnnptom. 

8.  Retrodisplacement  of  the  Uterus,  with  inflammation.  It  is  surprising 
how  much  displacement  of  the  uterus,  with  forward  projection  of  the  cervix 
and  apparent  blocking  of  the  vagina,  can  take  place  without  occasioning  any 
particular  disturbance  in  coitus.  But  if  iiiflammation  appears,  then  dys- 
pareunia  is  often  marked — ^much  more  so  than  from  the  same  amount  of  in- 
flammation without  displacement. 

9.  Bladder  or  Rectal  Diseases  occasionally  cause  painful  coitus,  particu- 
larly inflammatory  diseases. 


SEXUAL    IMPOTENCE  1019 


Treatment 


The  treatment  of  dyspareunia  is  indicated  by  the  particular  condition 
present,  as  determined  by  a  careful  examination. 

1.  If  there  is  some  malformation  about  the  vaginal  orifice  (imperforate 
hymen,  thick  hymen,  septum  in  vagina,  organic  stenosis  of  vagina),  the  ob- 
struction must  be  removed  by  the  necessary  operative  measures. 

2.  If  coitus  is  interfered  with  by  tender  areas  about  the  vaginal  entrance, 
or  by  ulcers  or  by  hyperesthesia,  the  following  measures  may  be  employed : 

a.  Abstinence  from  sexual  intercourse  for  one  to  three  weeks. 

b.  Hot  vaginal  douches  once  or  twice  daily — medicated  or  unmedi- 

cated,  depending  upon  the  presence  of  discharge. 

c.  Laxatives  as  needed.     Chronic  constipation  increases  the  conges- 

tion and  irritability  of  the  structures. 

d.  Some  sedative  ointment — for  example,  chloretone  ointment    (10 

per  cent),  applied  two  or  three  times  daily. 

e.  Bromides,  if  there  is  much  nervous  irritability  or  apparent  hyper- 

esthesia of  reflex  centers. 

f.  When  intercourse  is  again  attempted,  the  patient  should  coat  all 

the  sensitive  surfaces  with  a  sedative  ointment.  The  chloretone 
ointment  above  mentioned  may  be  used  or,  if  that  is  not  effect- 
ive, an  ointment  containing  2  to  5  per  cent  of  cocaine. 

3.  If  the  vaginal  opening  is  too  small  or  there  is  the  spasmodic  condition 
known  as  vaginismus,  stretching  of  the  opening  is  to  be  employed  in  addition 
to  the  other  measures  just  detailed.  In  some  cases  the  tendency  to  spasm  may 
be  overcome  by  gradual  stretching  with  a  speculum  every  few  days  without 
anesthesia.  In  cases  of  organic  narrowing  it  is  advisable  to  pack  the  vagina 
in  order  to  hold  what  has  been  gained  and  to  aid  in  securing  relaxation.  If 
the  gradual  stretching  without  anesthesia  fails,  then  the  patient  should  be 
anesthetized  and  the  vaginal  opening  thoroughly  stretched.  If  the  opening 
does  not  stretch  well  or  the  tendency  to  spasm  is  marked,  it  is  well  to  divide 
the  constricting  structures  and  close  the  wound  over  them  by  sutures. 

The  treatment  of  the  other  organic  lesions  mentioned  under  causes  is  taken 
up  in  detail  in  the  appropriate  chapters. 

SEXUAL  IMPOTENCE 

The  absence  of  strong  sexual  feeling  in  the  woman  during  coitus  does  not 
assume  the  serious  aspect  it  does  in  the  man,  with  whom  erection  is  necessary 
to  insemination  leading  to  pregnancy.  The  strong  sexual  feeling,  with  its 
consequent  orgasm,  in  the  woman  is  not  at  all  necessary  to  impregnation, 
though  it  increases  the  probability  of  impregnation.  From  the'  history  of  cases 
of  sexual  disturbance  it  is  evident  that  many  otherwise  normal  women  have 
little  or  no  sexual  feeling  until  some  months  or  years  after  marriage — some- 


1020  DISTURBANCES   OF   FUNCTION 

times  not  until  after  one  or  more  children  are  born.  The  response  to  sexual 
excitement  apparently  grows  with  the  proper  exercise  of  the  sexual  functions. 
This  fact  is  important  and  may  be  used  to  prevent  discord  and  disruption  in 
families  where  either  the  husband  or  the  wife  is  becoming  dissatisfied  and  de- 
spondent because  it  is  felt  that  there  is  not  the  proper  sexual  response. 

Again,  there  are  cases  in  which  the  wife  is  not  in  physical  condition  ta 
respond.  She  has  some  chronic  trouble  which  so  saps  her  strength  that  she 
has  not  the  vitality  for  this  function.  This  loss  of  strength  may  be  due  either 
to  some  general  condition  or  to  some  local  condition,  or  to  both.  It  is  hardly 
necessary  to  name  the  various  conditions.  They  comprise  the  whole  list  of 
debilitating  conditions,  both  general  and  local. 

The  treatment  of  sexual  impotence  is  directed  toward  removing  any  local 
disease,  and  toward  building  up  the  general  health  to  the  highest  point— by 
a  long  course  of  tonics  (including  iron,  strychnia,  etc.),  by  change  of  environ- 
ment, and  by  rest  from  care  and  worry  and  overwork,  and  too  frequent  sexual 
intercourse.  The  rest  indicated  is  very  important,  for  the  things  mentioned 
tend  to  keep  the  patient  dragged  down  below  par  and  in  no  condition  to  re- 
spond buoyantly  and  vigorously  to  any  of  the  mental  or  physical  requirements 
of  daily  life. 

STERILITY 

Sterility  is  the  absence  of  pregnancy  under  circumstances  that  normally 
lead  to  pregnancy. 

It  is  said  that  about  10  per  cent  of  marriages  are  without  offspring,  and 
the  popular  impression  is  that  this  sterility  is  nearly  always  due  to  some  defect 
or  disorder  in  the  genital  organs  of  the  woman.  The  woman  receives  almost 
altogether  the  blame  for  the  inability  to  produce  offspring.  In  many  cases  the 
defect  is  with  the  woman,  but  in  many  other  cases  this  blame  is  placed  upon  her 
unjustly.  If  we  exclude  from  the  definition  of  sterility  those  cases  in  which 
the  failure  to  produce  offspring  is  due  to  early  abortions,  or  to  prevention  of 
conception,  then  sterility  is  in  a  large  proportion  of  the  cases,  if  not  in  the 
majority  of  them,  due  primarily  to  the  husband.  In  that  large  class  of  cases 
in  which  the  immediate  cause  of  the  sterility  is  gonorrheal  inflammation  involv- 
ing the  tubes  and  ovaries,  the  primary  cause  lies  with  the  husband  and  on 
him  must  rest  the  blame  for  the  childless  home. 

Sterility  is  sometimes  defined  as  the  inability  to  bring  forth  a  living  child,, 
even  if  the  child  actually  is  carried  to  full  time.  But  it  seems  preferable 
to  limit  the  term  to  the  cases  of  absence  of  pregnancy.  This  is  sometimes 
designated  as  ''absolute  sterility."  Therefore,  considering  sterility  from  the 
gynecologic  standpoint,  let  the  definition  be  "the  inability  to  become  preg- 
nant. ' '  The  patient  may  have  had  children  or  abortions  in  former  years,  or  she 
may  not.  At  any  rate,  she  does  not  become  pregnant  now,  though  she  earnestly 
desires  to  be  so. 


STERILITY  1021 


Causes 


In  order  to  assist  in  determining  the  exact  cause  of  the  sterility  in  the 
Tarious  cases,  it  is  well  to  consider  what  is  necessary  that  a  normal  pregnancy 
may  take  place.  It  is  necessary  ordinarily  (a)  that  healthy  spermatozoa  be 
deposited  in  the  vagina,  (b)  that  the  spermatozoa  remain  healthy  and  penetrate 
into  the  uterine  cavity  and  into  the  Fallopian  tubes,  (c)  that  a  healthy  ovum 
be  formed  in  the  ovary,  (d)  that  it  find  its  way  into  the  Fallopian  tube,  where 
it  can  be  fertilized  by  a  spermatozoon,  (e)  that  the  fertilized  ovum  pass  into  the 
uterus,  and  (f )  that  it  find  there  an  endometrium  suitable  for  its  implantation 
and  de^-elopment. 

Some  of  these  conditions  are  not  always  absolutely  necessary.  At  least 
five  cases  of  conception,  with  labor  at  term,  have  taken  place  in  patients  where 
both  Fallopian  tubes  and  presumably  both  the  ovaries  were  removed.  Of 
course,  some  ovarian  tissue  was  left.  But  the  tubes  may  be  removed  and  still 
the  openings  in  some  cases,  without  doubt,  reopen  and  permit  the  ovum  to  pass. 
Fritsch  ligated  both  Fallopian  tubes  in  the  middle  with  silk  and  still  pregnancy 
followed  three  years  later.  Ashton  reported  the  occurrence  of  pregnancy  in 
the  cervix  following  removal  of  the  body  of  the  uterus  for  fibromyomata,  show- 
ing that  even  the  body  of  the  uterus  was  not  absolutely  essential  to  pregnancy. 
Again,  pregnancy  has  occurred  in  cases  where  penetration  of  the  male  organ 
into  the  vagina  was  impossible,  showing  that  the  si)ermatozoa  may  pass  from 
the  external  genitals  up  to  the  uterus.  But  these  are  all  very  exceptional  cases. 
Ordinarily  each  of  the  conditions  mentioned  is  a  bar  to  pregnancy. 

Assuming  that  the  husband  furnishes  healthy  spermatozoa,  the  sterility 
may  be  due  to  the  f olloAving  causes : 

1.  Some  Conditions  Interfering-  with  Coitus.  These  conditions  are  con- 
sidered under  ^'dyspareunia"  (page  1017). 

2.  Laceration  of  Pelvic  Floor.  When  there  has  been  a  marked  laceration, 
the  vagina  may  be  so  relaxed  and  patulous  that  the  semen  is  not  retained  in 
•contact  with  the  cervix  long  enough  for  the  spermatozoa  to  pass  up  into  the 
uterine  cavity. 

3.  Vaginitis,  or  Profuse  Discharge  in  the  Vagina  may  interfere  chemically 
vrith  the  vitality  of  the  spermatozoa  or  mechanically  with  their  progress  to,  or 
■entrance  into,  the  cervix  uteri.  In  either  case  the  chance  of  pregnancy  is 
diminished. 

4.  Some  Obstruction  in  the  Cervical  Canal,  a.  Stenosis  of  external  os. 
This  may  be  found  in  the  form  of  the  congenital  "pin-hole"  os  or  it  may  be 
■due  to  scar-tissue  resulting  from  former  injuries. 

b.  Stenosis  at  internal  os.  This  may  be  due  to  scar-tissue,  but  it  is  more 
frequently  due  to  a  sharp  anteflexion  of  the  cervix.  It  is  often  combined  with 
a  long  pointed  cervix  and  the  "pin-hole"  os  already  mentioned.  This  com- 
bination is  a  frequent  cause  of  sterility  in  women  who  have  never  been  preg- 
nant, and  it  is  usually  accompanied  with  dysmenorrhea.  . 


1022  DISTURBANCES   OF   FUNCTION 

'> 

c.  Discharge.    There  may  be  m  the  cervical  canal  an  excessive,  secrecioi  _ 
discharge  which  interferes  mechanically  with  their  journey  upward;    It  has  also 
been  shown  lately  that  acidity  of  the  normally  alkaline  uterine  mucus  quickl; 
destroys  the  spermatozoa  and  thus  may  be  the  cause  of  sterility. 

5.  Some  Displacement  of  the  Uterus,  a.  Eetrodisplacement  Retrodis- 
placement  of  the  uterus  may  throw  the  cervix  so  far  forward  that  the  sper- 
matozoa do  not  readily  enter  it. 

b.  Anteflexion.  Sharp  anteflexion  of  the  cervix  may  also  throw  the  cer- 
vical opening  too  far  forward. 

c.  Decided  Prolapse.  Prolapse  of  the  uterus  may  interfere  mechanicali^ 
with  coitus  or  with  the  passage  of  the  spermatozoa  to  the  interio:'.  "'^  the  uteruL. 

6.  Some  Abnormal  Condition  Within  the  Uterine  Cavity,  wTAoh  intetfer 
with  the  passage  of  the  spermatozoa  to  the  tubes,  or  which  fails  to  fumi' 
a  proper  place  for  the  implantation  and  nourishment  of  the  fertilized  ovi 

a.  Hyperplasia  of  Endometrium. 

b.  Infected  Endometritis. 

c.  Tuberculosis  of  the  Endometrium. 

d.  Malignant  disease  (Carcinoma  or  Sarcoma). 
6.  Fibromyoma. 

7.  Some  Affection  of  the  Fallopian  Tubes  which  interferes  with  the  e) 
trance  of  the  spermatozoa  into  the  tube  or  with  the  entrance  of  the  ovuif 
into  the  tube,  or  with  the  passage  of  the  fertilized  ovum  from  the  tube  intt 
the  uterus. 

a.  Inflammation.  Inflammation  of  the  tube  is  the  most  frequent  cause  of 
sterility  from  tubal  disturbance.  This  may  be  very  slight — not  enough  to 
produce  symptoms  nor  physical  signs,  but  just  enough  to  cause  occlusion  of 
one  or  both  ends  of  the  tube.  It  may  vary  all  the  way  from  this  mild  form  to 
severe  inflammation  and  disorganization  of  the  tube,  with  extensive  exudate 
and  adhesions  and  abscess  formation.  Salpingitis,  coming  on  after  the  first 
childbirth,  or  miscarriage,  because  of  inflammation  during  the  puerperium  or 
because  of  gonorrheal  infection  brought  by  the  husband,  who  was  untrue  to 
his  wife  during  her  confinement,  is  a  prolific  source  of  the  so-called  **one 
child  sterility." 

b.  Tuberculosis.     Tuberculosis  of  tubes  and  adjacent  structures. 

c.  Tumor.  A  tumor  of  the  tube  or  in  the  vicinity  of  the  tubes,  interfering 
with  their  functions. 

d.  Malformation  of  the  Tubes.  This  may  consist  in  atresia  of  one  or  both 
ends  of  the  tubes,  or  in  blind  passages  and  diverticula  into  which  the  ovur^ 
may  wander  and  lodge.  Or  there  may  be  abnormal  openings  in  the  wall  of 
the  tube  through  which  the  ovum  may  pass  out  into  the  peritoneal  cavity 
and  be  lost.  '      ' 

8.  Some  Affection  of  the  Ovaries  that  interferes  with  their  function  to  such 
an  extent  that  healthy  ova  are  not  formed  or  are  not  discharged  in  such  a 
way  that  they  pass  into  the  Fallopian  tubes. 


STERILITY  "^  1023 

:af]an:niation. — Inflammation  of  the  ovary  may  be  present  in  some  of 
•^  various  forms — infected  oophoritis,   simple   oophoritis,   cystic  ovary,   cir- 
otic  ov^ry  or  an  ovary  covered  with  exudate  and  adhesions. 

b.  Tuberculosis  of  ovaries  and  vicinity. 

c.  Tumo.  s  of  the  ovary. 

d.  Displacement  of  the  ovary. — This  may  be  so  marked  that  the  ova,  in- 
ead  of  passing  into  a  Fallopian  tube,  where  they  would  be  fertilized,  pass 
""^  the  peritoneal  cavity  and  perish. 

9.  Certain  Operations — for  example,  removal  of  the  uterus  or  of  the  Fallo- 
)ian  tubes,  or  cf  both  ovaries. 

10.  Douc    3b,  which  may  interfere  chemically  or  mechanically  with  the 
o<.3S  of  impregnation. 

\1.  General  Conditions.     The  general  health  may  be  so  poor  that  all  the 

ans  of  the  body  are  in  too  poor  a  condition  to  properly  functionate,  the 

c»,^/'tal  organs  among  them.    This  is  seen  in  some  cases  of  marked  anemia  and 

i^.ciation,  and  general  depression.    On  the  other  hand,  it  is  present  at  times 

patients  who  are  inclined  to  stoutness.    The  effect  of  obesity  in  diminishing 

nstruation  has  been  mentioned,  and  it  sometimes  has  much  the  same  effect 

the  capacity  for  impregnation.     It  has  happened  that  sterility  cam©  on 

3n  a  patient  accumulated  fat  and  disappeared  promptly  on  reduction  to  her 

jal  weight. 

Diagnosis 

A  couple  come  to  consult  you  because  they  have  no  children.  Your  prob- 
lem is  to  find  the  cause  of  the  sterility  in  this  particular  case.  If  the  husband 
is  an  intelligent  man,  he  will  speak  of  any  genital  disturbance  which  he  has 
had  that  might  have  a  bearing  on  the  subject.  If  no  explanation  is  made,  it 
is  to  be  assumed  that  the  husband  is  healthy,  though  this  assumption  should 
-•e  confirmed  as  soon  as  opportunity  occurs  of  questioning  him  when  the  wife 
is  not  present.  Gross  found  the  male  directly  at  fault  in  about  16  per  cent 
of  the  cases  of  sterility  and  De  Sinty  found  the  trouble  to  lie  with  the  male  in 
25  per  cent  of  the  cases.  The  chief  causes  in  the  male  were  impotence,  or 
absence  of  semen  or  absence  of  living  spermatozoa.  If  there  is  any  question 
as  to  the  ability  of  the  husband  to  perform  Ms  part  in  the  process  of  impreg- 
nation, a  specimen  of  the  semen  should  be  submitted  to  microscopic  exami- 
nation, that  the  presence  or  absence  of  living  spermatozoa  may  be  positively 
esodblished. 

Assuming  that  the  husband  is  healthy,  the  wife  is  questioned  to  secure  the 
systematic  gynecologic  history  and  to  bring  out  any  special  facts  that  may 
have  a  bearing  on  the  sterility.  The  history  may  point  decidedly  to  some 
serious  pelvic  disorders,  or  there  may  be  nothing  in  the  history  to  indicate 
that  the  pelvic  organs  are  other  than  normal.     A  thorough  pelvic  examina- 


1024  DISTURBANCES    OF   FUNCTION 

tion  is  then  made  to  determine  if  there  is  any  pathologic  condition  in  the 
genital  tract. 

The  various  conditions  that  may  give  rise  to  sterility,  together  with  their 
diagnostic  points,  have  just  been  detailed  under  "causes." 

Treatment 

1.  If  there  is  difficulty  in  coitus,  treatment  for  that  will  be  required.  This 
is  considered  in  detail  under  dyspareunia  (page  1017). 

2.  There  may  be  anteflexion  of  the  cervix,  with  stenosis  in  the  canal,  a 
frequent  cause  of  sterility  in  patients  who  have  never  been  pregnant.  Where 
sterility  results  from  this  condition,  the  treatment  is  dilatation  of  the  canal,  and 
for  this  there  are  three  methods,  as  follows : 

a.  Partial  Dilatation  Withotit  Anesthesia.  The  details  of  this  procedure  ar, 
employed  for  sterility  are  the  same  as  described  under  Dysmenorrhea,  except 
that  the  dilatation  is  made  immediately  after  each  menstrual  flow  instead  of 
before  the  flow.  Just  after  menstruation  is  supposed  to  be  the  most  favorable 
time  for  impregnation,  so  the  canal  is  dilated  then  and  it  remains  somewhat 
dilated  for  a  week  or  so.  The  patient  is  directed  to  take  no  douches  unless 
there  is  a  troublesome  discharge.  If  there  is  a  discharge  necessitating  douches, 
a  saline  douche  (a  tablespoonful  of  table  salt  to  two  quarts  of  warm  water) 
should  be  used  and  the  douche  should  be  taken  in  the  evening — not  in  the 
morning.  No  antiseptic  douche  is  allowed  because  it  interferes  with  impreg- 
nation. This  treatment  may  be  repeated  after  each  menstrual  flow  for  several 
months,  until  pregnancy  takes  place  or  until  it  is  apparent  that  no  result  is  to 
be  accomplished  by  this  method. 

In  many  cases  more  radical  measures  are  necessary.  In  some  cases,  how- 
ever, the  simple  dilatation  just  described  carried  out  a  few  times  will  put  the 
parts  in  such  condition  that  pregnancy  ensues,  and  it  is  worthy  of  trial  in  all 
cases  where  the  canal  dilates  readily  and  there  is  not  a  profuse  uterine  dis- 
charge. In  one  of  my  patients,  pregnancy  followed  a  single  such  treatment 
made  after  several  years  of  sterility. 

1).  Thorough  Dilatation  Under  Anesthesia.  The  patient  is  anesthetized, 
the  cervix  widely  dilated  and  the  interior  of  the  uterus  curetted.  The  curet- 
ment  is  advisable  in  practically  all  such  cases,  for  the  endometrium  is  usually 
not  entirely  healthy. 

This  thorough  dilatation  under  anesthesia  is  employed  in  cases  in  which 
the  previous  method  fails  to  produce  results.  It  is  advisable  as  the  primary 
treatment  in  those  cases  where  the  cervix  is  small  and  sensitive.  The  dilata- 
tion thus  secured  is  likely  to  persist  in  a  measure  over  several  months,  and 
thus  gives  a  good  chance  of  pregnancy. 

c.  The  Dudley  Operation.  This  is  explained  and  illustrated  under  Dj's- 
menorrhea.  It  is  employed  for  the  purpose  of  permanently  overcoming  the 
obstruction  in  ca.ses  where  the  stenosis  tends  to  recur  after  wide  dilatation 
under  anesthesia. 


LEUCORRHEA  1025 

3.  There  may  be  inflammation  of  the  cervix,  with  discharge,  which  inter- 
feres with  the  vitality  or  upward  progress  of  the  spermatozoa.  Such  a  con- 
dition requires  the  treatment  for  endocervicitis,  see  Chapter  vi. 

4.  Laceration  of  the  Cervix,  with  consequent  cystic  degeneration  and  dis- 
charge, may  be  present  and  requires  the  usual  measures  to  allay  the  inflamma^ 
tion  and  lessen  the  discharge.  If  these  palliative  measures  are  not  effective, 
the  cervix  should  be  put  in  better  condition  by  an  op^^ation  for  repair — being 
careful  in  the  denudation  to  leave  a  wide  cervical  canal,  so  that  there  will 
be  no  resulting  stenosis.  This  removes  the  chronically  inflamed  and  discharg- 
ing surfaces,  and  thus  increases  the  chance  of  the  spermatozoa  being  able  to 
penetrate  into  the  uterus. 

5.  If  there  is  marked  chronic  endometritis,  that  must  receive  appropriate 
treatment — which  will  include  usually  a  thorough  euretment. 

6.  Retrodisplacement  of  the  uterus  may  be  present.  If  so,  it  requires  the 
treatment  detailed  in  Chapter  vii. 

7.  Tumors  in  the  uterus,  or  elsewhere  in  the  pelvis,  must  be  removed  when 
it  is  at  all  probable  that  they  are  a  factor  in  the  sterility. 

8.  Pelvic  Inflammation  in  one  of  its  various  forms  may  be  found.  If  the 
inflammation  is  of  recent  origin  and  there  are  no  serious  symptoms,  employ 
palliative  measures.  If  the  pelvic  inflammation  is  improved  thereby,  these 
palliative  measures  may  be  kept  up  for  several  months  in  the  hope  that  nature 
will  repair  the  damaged  organs  sufficiently  to  restore  their  function.  For  the 
prognosis  in  regard  to  pregnancy  after  pelvic  inflammation  see  page  833. 

In  chronic  pelvic  inflammation  the  chance  of  pregnancy  may  in  some  cases 
be  decidedly  increased  by  the  removal  of  the  disorganized  portions  of  the 
Fallopian  tubes  and  special  treatment  of  the  remaining  part.  The  special 
treatment  consists  of  splitting  open  the  distal  end  of  the  stump  of  the  tube  for 
some  little  distance  and  sewing  it  open,  and  then  establishing  the  patency  of 
the  tube,  if  practicable,  from  the  distal  end  to  the  uterine  cavity. 

9.  If  No  Local  Lesion  is  found,  improve  the  general  health  (by  the  use  of 
tonics,  and  exercise  and  other  appropriate  measures)  and  make  particular 
investigation  as  to  the  husband's  condition.  In  regard  to  the  patient's  general 
health,  if  she  is  too  stout,  her  Aveight  should  be  reduced. 

10.  If  the  patient  has  been  taking  douches  for  the  treatment  of  any  dis- 
order or  as  a  routine  measure,  stop  them.  In  cases  where  a  douche  is  really 
necessary,  direct  the  patient  to  employ  the  saline  douche,  and  to  postpone  its 
use  for  at  least  eighteen  hours  after  sexual  intercourse. 

LEUCORRHEA 

There  is  normally  a  slight  muco-epithelial  discharge  about  the  genitals, 
sufficient  to  keep  the  parts  properly  moist.  Abnormal  discharge  may  be  only 
an  increase  in  the  normal  muco-epithelial  discharge,  or  the  discharge  may  be 
muco-purulent  in  character,  or  watery  or  bloody,  as  explained  on  page  62. 


1026  DISTURBANCES    OF   FUNCTION 

For  convenience  the  various  kinds  of  discharge  may  be  grouped  under  the 
two  terms,  leucorrhea  and  bloody  discharge.  These  disturbances  are  not 
diseases,  but,  like  the  other  disturbances  of  function,  are  only  symptoms. 

Under  the  term  "leucorrhea"  are  included  all  varieties  of  pathologic  dis- 
charge from  the  genitals,  except  discharge  containing  blood. 

Causes  and  Diagnosis 

Leucorrhea  due  to  extragenital  disturbances  only  and  without  local 
change  is  hardly  probable,  for  the  leucorrhea  is  in  itself  evidence  of  some 
local  departure  from  the  normal  functional  activity.  Of  course,  there  are  in- 
stances, particularly  in  virgins,  in  which  the  functional  disturbance  evidenced 
by  the  leucorrhea  is  dependent  largely  on  malnutrition  or  on  pelvic  con- 
gestion from  extragenital  causes.  The  mild  leucorrhea  found  in  anemic  or 
cachectic  patients  may  disappear  when  the  patient  is  put  in  good  general 
health.  Again,  in  pelvic  congestion  from  heart  disease,  or  from  some  general 
cause,  there  may  be  present  a  mild  leucorrhea,  which  disappears  when  the 
functional  pelvic  congestion  is  corrected.  In  this  sense  leucorrhea  may  be 
said  in  some  cases,  to  be  due  to  extragenital  causes  and  its  relief  to  depend 
upon  treatment  of  same.  In  all  but  these  exceptional  cases,  discharge  from  the 
genitals  is  due  to  one  of  the  following  local  conditions : 

Inflammation  or  Ulcer  of  Vulva.  There  is  a  history  of  discharge  from  the 
vulva,  of  burning  or  itching,  and  of  frequent  urination,  with  perhaps  some  pain. 
Examination  of  the  external  genitals  shows  redness,  either  general  or  localized 
to  certain  areas.  There  is  tenderness  and  discharge,  and  also  evidences  of  the 
cause  of  the  inflammation  or  ulcer.  If  the  trouble  is  an  ulcer,  it  may  be  simple, 
chancroidal,  syphilitic,  tubercular  or  malignant. 

Acute  Vaginitis.  There  is  a  history  of  a  free  yellow  discharge  of  short 
duration,  irritation  of  vulva  and  frequent  urination,  with  some  burning.  Ex- 
amination shows  a  yellowish  discharge  and  redness  of  vulva.  If  gonorrheal, 
there  is  usually  involvement  of  the  vulvo-vaginal  glands;  also  the  discharge 
shows  gonococci.  The  vaginal  walls  are  rough  and  hot  and  tender — too  tender 
to  admit  of  satisfactory  bimanual  examination.  When  exposed  with  the  specu- 
lum, the  vaginal  walls  are  reddened  and  there  is  not  enough  discharge  from  the 
cervix  to  account  for  the  leucorrhea. 

Chronic  Vaginitis.  This  occurs  principally  in  children.  There  has  been  a 
yellow  discharge  for  several  weeks  or  months,  with  irritation  of  the  vulva  and 
some  bladder  irritability.  Examination  shows  a  yellow  discharge  and  redness 
of  the  vulva,  with  more  or  less  tenderness.  The  discharge  should  be  examined 
for  gonococci.  If  the  patient  is  a  child,  no  vaginal  examination  is  made.  If  an 
adult,  examination  shows  tenderness  and  chronic  thickening  and  roughness  of 
vaginal  wall,  usually  most  marked  in  the  posterior  fornix.  Speculum  examina- 
tion shows  redness  of  vaginal  wall,  either  general  or  in  patches,  and  there  is  not 
enough  discharge  from  the  cervix  to  account  for  the  leucorrhea. 


LEUCORRHEA  1027 

Adhesive  Vaginitis.  This  occurs  principally  near  or  after  the  menopause. 
There  is  a  history  of  chronic  discharge,  with  irritation  of  the  vulva,  and  some- 
times bladder  irritability.  On  examination  it  is  found  in  most  cases  that  the 
discharge  is  slight  and  is  sticky  or  ''gluey"  in  character,  though  in  exceptional 
cases  it  is  free  and  purulent.  In  some  cases  there  ^re  scratch  marks,  resulting 
from  the  patient's  attempts  to  overcome  the  pruritus.  On  vaginal  examination 
the  vaginal  walls  are  found  adherent  in  spots,  especially  at  the  upper  part  of  the 
vagina.  If  the  adhesions  are  recent,  they  separate  easily,  with  some  bleeding. 
If  the  adhesions  are  old,  they  are  firm,  and  in  some  cases  the  vagina  is  almost 
obliterated  by  the  process.  When  the  walls  are  separated  with  the  speculum, 
in  the  less  advanced  cases,  irregular  spots  may  be  seen  which  are  raw  and 
bleed  slightly. 

Ulcer  of  Vagina.  This  may  be  simple,  chancroidal,  syphilitic,  tubercular, 
or  malignant.  There  is  a  history  of  an  acute  or  chronic  discharge  and  prob- 
ably also  of  other  evidences  of  the  disease  causing  the  ulceration.  Exam- 
ination shows  a  discharge  about  the  \Tilva  and  more  or  less  irritation  of  the 
surfaces.  When  making  the  vaginal  examination,  the  indurated  edges  or  base 
of  the  ulcer  may  be  felt.  The  speculum  exposes  the  ulcer  to  view,  and  further 
investigation  shows  it  to  be  the  sufficient  cause  of  the  discharge. 

Acute  Endo cervicitis.  There  is  a  history  of  a  tenacious,  stringy  discharge 
of  recent  origin.  There  may  or  may  not  be  irritation  of  the  external  genitals. 
Vaginal  and  bimanual  examination  show  nothing  special.  Speculum  exam- 
ination shows  a  stringy,  tenacious  discharge  coming  from  the  external  os. 
There  is  also  congestion  of  the  cervix  and  usually  erosion  about  the  external  os. 

Chronic  Endocervicitis.  There  has  been  a  discharge  for  a  long  time.  Vag- 
inal and  bimanual  examination  show  no  evidence  of  involvement  of  the  cor- 
pus uteri  or  the  adnexa.  Speculum  examination  shows  a  very  tenacious, 
stringy,  muco-purulent  discharge  from  the  external  os,  with  more  or  less 
surrounding  erosion.  In  many  cases  there  has  been  also  severe  laceration  of  the 
cervix,  the  evidences  of  which  may  be  felt  and  seen. 

Laceration  of  Cervix.  In  these  cases  the  discharge  is  not  due  so  much 
to  the  tear  itself  as  to  the  subsequent  eversion,  and  irritation  and  chronic  in- 
flammation. The  various  appearances  presented  by  the  lacerated  cervix  are 
shown  in  Figs.  413  to  418. 

Ulcer  of  Cervix.  Such  an  ulcer  may  be  simple,  chancroidal,  syphilitic, 
tubercular  or  malignant.  There  is  a  history  of  leucorrhea.  In  the  vaginal 
examination  the  ulcer  of  the  cervix  may  or  may  not  be  felt,  depending  on 
whether  or  not  there  is  any  induration  in  the  edges  or  base.  When  the  cervix 
is  exposed  with  the  speculum,  the  ulcer  is  seen,  presenting  a  distinctly  marked 
margin  and  a  base  of  granulation  tissue. 

Malig-nant  Disease  of  Cervix.  This  may  appear  in  the  form  of  an  ulcer, 
with  indurated  margins  and  base,  or  as  a  papillary  growth  from  some  spot  on 
the  cervix  or  Avithin  the  cervix.  For  the  various  appearances  of  beginning 
malignant  disease  of  the  cervix  see  Figs.  419  to  423. 


1028  DISTURBANCES    OF    FUNCTION 

Polypi  of  Cervix.  Polypi  of  the  cervix  of  various  kinds  may  give  rise  to 
considerable  leucorrhea,  though  usually  a  bloody  discharge  is  the  prominent 
feature  in  these  cases  (page  625). 

Acute  Endometritis,  whether  gonorrheal  or  due  to  pus  infection  following 
labor  or  miscarriage,  gives  rise  to  free  discharge.  There  is  a  history  of  recent 
labor  or  miscarriage,  or  instrumentation  or  gonorrhea,  or  a  history  of  chronic 
endometritis  due  to  one  of  these  causes.  Examination  shows  a  free  discharge, 
the  character  of  which  points  to  the  cause  of  the  trouble,  as  explained  in 
Chapter  vi.  Vaginal  and  bimanual  examination  show  tenderness  of  the  body 
of  the  uterus,  but  no  tenderness  around  the  uterus  unless  there  is  complicating 
trouble.  Speculum  examination  shows  a  free  purulent  discharge  coming  from 
the  uterus. 

Chronic  Endometritis.  There  is  a  history  of  chronic  leucorrhea.  Exam- 
ination shows  nothing  in  the  vagina  or  cervix  to  account  for  the  discharge. 
The  body  of  the  uterus  may  be  somewhat  enlarged  or  tender,  though  not  nec- 
essarily so.  Through  the  speculum  it  is  seen  that  the  discharge  comes  from 
the  uterus  and  not  from  inflammation  of  the  vaginal  wall.  The  character  of 
the  discharge  indicates  that  it  comes  largely  from  the  endometrium  and  not 
from  the  cervical  glands. 

Retrodisplacement  of  Uterus  causes  leucorrhea  when  associated  with  a 
chronic  endometritis. 

Fibroid  of  Uterus  causes  leucorrhea  by  causing  chronic  irritation  of  the 
endometrium,  both  by  direct  pressure  and  by  interference  with  its  blood 
supply. 

Cancer  of  Corpus  Uteri  causes  leucorrhea  by  the  breaking  down  of  the 
cancerous  area  and  also  by  the  chronic  irritation  of  the  adjacent  endometrium. 

Periuterine  Disease  causes  leucorrhea  by  causing  chronic  congestion  of 
the  endometrium,  with  the  resulting  endometritis. 

Functional  Congestion  of  the  uterus  or  pelvis  causes  leucorrhea  by  the 
nutritive  and  so-called  inflammatory  changes  in  the  endometrium  and  cervical 
mucosa  resulting  therefrom. 

Treatment 

For  the  purpose  of  considering  treatment,  it  is  convenient  to  divide  the 
cases  of  leucorrhea  into  three  classes. 

1.  In  the  Virgin.  Leucorrhea  is  not  an  infrequent  complaint  in  the  virgin. 
It  ma,y  be  due  to  local  malnutrition  and  loss  of  tone  from  marked  anemia 
(dependent  on  chlorosis  or  other  cause),  it  may  be  due  to  pelvic  congestion 
from  obstruction  to  circulation  by  heart  disease  or  liver  disease,  or  other 
extragenital  affection,  or  it  may  be  due  to  functional  pelvic  congestion  incident 
to  the  occupation  or  other  condition  mentioned  under  Menorrhagia  (page  989). 
In  the  virgin  it  is  assumed  that  the  leucorrhea. is  due  to  one  of  these  causes, 
unless  evidences  of  decided  local  disease  are  present,  and  treatment  is  given 
accordingly.     The  treatment  consists  of  the  following  measures: 


LEUCORRHEA  1029 

a.  The  administration  of  iron  and  other  tonics  internally  and  the  employ- 
ment of  the  other  measures  mentioned  in  the  tonic  regimen  for  the  treatment 
of  anemia  accompanying  amenorrhea  (page  979). 

b.  The  use  of  laxati^'es  and  other  measures  required  to  overcome  any 
chronic  constipation  that  may  be  present. 

c.  The  administraton  of  some  uterine  astringent  for  the  purpose  of  dimin- 
ishing the  congestion  of  the  endometrium.  Ergotin  is  a  very  good  prepara- 
tion for  that  purpose.  The  uterine  astringent  is  specially  indicated  for  those 
cases  accompanied  with  excessive  menstruation. 

d.  AYhere  the  discharge  persists  after  the  patient  has  been  put  in  good 
general  health  by  the  measures  mentioned  above,  a  vaginal  douche  may  be 
ordered  to  be  taken  once  or  twice  daily.  It  is  well  to  start  with  a  mildly 
astringent  solution,  such  as  the  alum  douche  (one  teaspoonful  of  powdered 
alum  to  two  quarts  of  hot  water)  or  the  aluminum  acetate  douche,  and  advance 
to  the  stronger  astringents,  such  as  the  zinc  sulphate  and  the  alum  douche,  if 
necessary. 

e.  Local  examination,  with  such  subsequent  treatment  as  is  necessary  for 
the  particular  local  lesion  found.  In  the  virgin  this  is  reserved  for  those 
cases  in  which  the  discharge  persists  after  the  employment  of  the  measures 
above  given  or  in  which  the  evidences  of  local  disease  are  so  marked  that  an 
examination  at  once  is  necessary. 

2.  With  Marked  Local  Lesion.  In  the  married  woman,  who  comes  com- 
plaining of  leucorrhea,  an  examination  is  ordinarily  made  at  once  in  order 
to  determine  if  any  marked  lesion  is  present.  In  these  cases,  and  also  in  ex- 
ceptional cases  of  the  previous  class  in  which  an  examination  is  finally  nec- 
essary, it  may  be  found  that  there  is  a  decided  local  lesion,  or  that,  on  the 
other  hand,  the  parts  show  no  decided  lesion. 

When  a  marked  lesion  that  constitutes  sufficient  cause  for  the  leucorrhea 
is  present,  it  should,  of  course,  receive  the  appropriate  treatment.  The  va- 
rious lesions  that  may  cause  a  discharge  from  the  genitals  have  just  been 
mentioned  in  the  preceding  pages,  and  the  treatment  required  for  each  lesion 
is  detailed  in  the  chapter  dealing  with  such  lesion.  In  many  of  these  cases  the 
leucorrhea  is  a  very  subordinate  feature,  the  treatment  being  principally  for 
the  relief  of  more  serious  symptoms.  In  the  case  of  many  patients  with  a 
chronic  uterine  discharge,  in  which  there  is  a  more  serious  disorder  requiring 
some  operative  procedure,  it  is  well  to  curet  the  interior  of  the  uterus  at  the 
same  time  in  order  to  cheek  the  discharge. 

3.  Without  Marked  Lesion.  In  some  patients  with  troublesome  leucorrhea 
the  examination  shows  no  marked  lesion.  There  is  probably  a  mild  chronic 
endometritis  or  hyperplasia  of  the  endometrium,  but  there  is  nothing  that 
gives  rise  to  any  symptoms  other  than  the  leucorrhea,  with  perhaps  a  slight 
tendency  to  excessive  menstrual  flow. 

In  such  a  case  employ  the  measures  just  mentioned  for  treatment  in  the 
virgin.    If  these  do  not  suffice,  then  a  few  astringent  intrauterine  applications 


1030  DISTUEBANCES    OF   FUNCTION 

(see  page  392)  may  be  made  if  the  cervix  dilates  easily,  or  a  few  intrauterine 
applications  of  electricity.  If  the  leucorrhea  still  persists  to  a  troublesome 
extent,  thorough  curetment  of  the  interior  of  the  uterus  under  anesthesia 
should  be  employed.  The  curetment  should  be  followed  by  a  general  and  local 
tonic  regimen,  that  the  new  endometrium  may  develop  under  bettered  con- 
ditions. 

In  suspicious  cases  of  persistent  uterine  discharge,  the  material  removed 
in  the  curetment  should  be  submitted  to  microscopic  examination,  that  the 
presence  or  absence  of  malignant  disease  of  the  endometrium  may  be  positively 
determined. 

BLOODY  DISCHARGE 

Bleeding  not  connected  with  menstruation  may  vary  from  a  streak  of 
blood,  or  a  slight  coloring  of  a  muco-purulent  discharge,  to  a  free  flow  of 
blood.  Occasionally  there  is  a  hemorrhage  sufficiently  free  to  threaten  the 
patient's  life.  In  most  cases,  however,  the  bloody  discharge  is  slight  and 
irregular,  and  is  of  serious  import  only  because  it  may  have  a  serious  con- 
dition for  its  cause. 

Causes 

Any  of  the  following  disorders  may  cause  a  bloody  discharge  from  the 
genitals,  the  character  of  the  discharge  varying  from  a  muco-purulent  dis- 
charge, only  streaked  with  blood,  to  a  profuse  flow  of  blood  and  clots.  All  of 
the  following  conditions  give  rise,  also,  to  leucorrhea: 

Inflammation  or  Ulcer  of  Vulva. 

Acute  Vaginitis. 

Chronic  Vaginitis. 

Adhesive  Vaginitis. 

Ulcer  of  Vagina. 

Acute  Endocervicitis. 

Chronic  Endocervicitis. 

Laceration  of  Cervix. 

Ulcer  of  Cervix. 

Cancer  of  Cervix. 

Polypi  of  Cervix. 

Acute  Endometritis. 

Chronic  Endometritis. 

Retrodisplacement  of  Uterus. 

Fibroid  of  Uterus. 

Cancer  of  Corpus  Uteri. 

Periuterine  Disease. 

Functional  Congestion. 


BLOODY   DISCHARGE  1031 

The  following  other  conditions  occur  with  pregnancy  and  must  be  thought 
of  whenever  a  bloody  discharge  is  complained  of: 

Threatened  Miscarriage.  The  patient  may  have  missed  the  menses  only  a 
few  days  or  may  be  several  months  pregnant.  Threatened  miscarriage  is 
usually  accompanied  by  considerable  pelvic  pain.  In  exceptional  cases  there 
may  be  a  bloody  discharge  for  several  hours,  or  a  day  or  two,  before  pains 
begin.  In  some  cases,  by  questioning  the  patient,  it  will  be  found  that,  failing 
to  come  unwell  at  the  proper  time,  she  has  been  taking  medicine  to  produce 
an  abortion  (''to  bring  on  the  flow"). 

Miscarriage.  Here  there  are  sharp,  cramp-like  pains,  with  the  expulsion 
of  blood  clots  and  pieces  of  membrane  or  a  formed  fetus,  depending  on  the 
period  of  pregnancy  at  which  the  accident  happens.  Then  the  pain  subsides 
and  after  a  few  days  the  bloody  discharge  ceases. 

Incomplete  Miscarriage.  The  uterus  is  not  entirely  emptied  and  the 
retained  remnants  cause  a  persistent  bloody  discharge  for  one  or  two  weeks 
after  it  should  have  stopped,  and  there  is  resulting  subinvolution  of  the  uterus. 
The  blood  may  pass  as  a  muco-sanguinous  discharge  or  in  clots.  It  may 
disappear  when  the  patient  stays  in  bed,  to  reappear  when  she  gets  up.  This 
is  perhaps  the  most  frequent  cause  of  persistent  bleeding  in  women  of  the 
child-bearing  age.  There  is  usually  little  pain  after  the  miscarriage  has  taken 
place.  The  principal  symptom  is  the  bleeding,  with  the  resulting  anemia  and 
weakness.    If  infection  takes  place,  the  symptoms  of  sepsis  are  added. 

Placenta  Previa.  Bleeding  from  this  cause  does  not  usually  take  place 
until  the  pregnancy  has  advanced  so  far  that  the  diagnosis  is  perfectly  clear. 

Laceration  of  Cervix  with  Pregnancy.  The  cervix  is  lacerated,  everted 
and  eroded,  and  there  is  added  the  softening  and  congestion  from  pregnancy. 
There  are  no  pains  such  as  accompany  miscarriage.  There  may  be  some  slight 
pain  and  uneasiness  in  pelvis,  which  is  relieved  by  lying  down.  The  bloody 
discharge  persists,  off  and  on,  without  apparent  evidence  of  threatened  mis- 
carriage or  other  intrauterine  disturbance. 

Tubal  Pregnancy.  The  rupture  of  a  tubal  pregnancy,  or  a  tubal  abortion, 
is  nearly  always  followed  in  a  few  days  by  an  irregular  bloody  discharge, 
which  may  persist  for  several  days  or  several  weeks.  In  some  cases  pieces 
of  membrane  are  associated  with  the  bloody  discharge.  There  are  also  the- 
other  evidences  of  tubal  pregnancy  (page  882). 

Myopathia  Hemorrhagica.  This  is  a  symptomatic  term  used  to  designate 
the  condition  in  certain  uteri  that  bleed  persistently  in  spite  of  repeated 
curettage,  without  sufficient  reason  so  far  as  any  gross  lesion  is  concerned. 
On  microscopic  examination  of  such  uteri,  some  are  found  to  have  marked 
disease  of  the  vessel  Avails  in  form  of  sclerotic  changes.  Others  seem  to  have 
an  abnormal  increase  in  the  amount  of  connective  tissue  in  the  myometrium, 
or  an  apparent  scarcity  of  elastic  fibers.  But  practically  all  show  a  rather 
normal  appearing  endometrium.     In  the  light  of  present  knowledge  such  a 


1032  DISTURBANCES    OF   FUXCTIOX 

metrorrliagia,  often  extremely  persistent,  is  caused  by  hyper  functional  activity 
of  the  ovaries  as  shall  be  discussed  in  the  next  chapter. 

Treatment 

In  considering  the  treatment  of  bloody  discharge  from  the  genital  tract,  it 
is  -vrell  to  divide  the  cases  into  two  classes — those  with  an  evident  local  lesion 
and  those  without  e^-ident  lesion. 

1.  With  Marked  Local  Lesion.  In  a  certain  proportion  of  the  cases  in 
which  the  patient  comes  complaining  of  a  bloody  discharge,  the  ordinary 
gynecologic  examination  will  show  a  marked  lesion  of  the  external  genitals,  or 
the  vagina  or  the  uterus,  of  such  nature  as  to  account  for  the  bloody  discharge. 
The  treatment  required  is  the  regular  treatment  for  the  particular  lesion,  the 
details  of  which  are  given  in  the  appropriate  chapter. 

AVhen  there  is  free  hemorrhage  from  the  uterus,  a  firm  vaginal  packing 
or  tamponade  may  be  used  for  temporary  effect.  This  is  best  applied  with 
the  patient  in  the  Sims  posture  and  the  perineum  retracted  with  the  Sims 
speculum.  The  gauze  or  cotton  used  for  the  packing  should  first  be  dipped 
in  an  antiseptic  solution  and  then  squeezed  as  dry  as  possible.  Gauze  or 
cotton  thus  prepared  is  much  more  eifective  for  checking  hemorrhage  than 
when  perfectly  dry.  Xo  firm  vaginal  packing  should  be  employed  in  a  preg- 
nant patient  as  long  as  there  is  a  chance  of  preserving  the  pregnancy,  as 
such  a  packing  might  cause  a  miscarriage. 

2,  Without  Marked  Local  Lesion.  The  ordinary  gynecologic  examination 
shows  no  decided  lesion.  It  is  evident  that  the  bloody  discharge  comes  from 
-odthiu  the  uterus,  but  the  history  and  examination  show  no  other  sign  of 
uterine  disease,  except  perhaps  some  menstrual  disturbance.  What  is  to  be 
done  for  such  a  patient? 

The  following  treatment  should  be  employed : 

a.  Tonics.  It  is  important  to  overcome  any  marked  anemia  or  general 
malnutrition  by  the  administration  of  iron  and  other  internal  remedies  as 
indicated  and  the  employment  of  the  other  measures  of  an  effective  tonic 
regimen. 

b.  Laxatives.  The  careful  regulation  of  the  bowels  is  needed,  both  for 
the  local  effect  in  diminishing  pelvic  congestion  and  for  the  general  effect  in 
improving  nutrition. 

c.  Uterine  Astringents.  Ergotin  or  stypticin- should  be  given  regularly, 
three  to  four  times  daily,  for  a  period  of  two  or  three  weeks  in  order  to 
secure  the  full  hemostatic  effect.  This  is  to  some  extent  a  diagnostic  meas- 
ure as  well  as  a  therapeutic  measure.  If  the  bloody  discharge  is  due  simply 
to  subinvolution  or  a  mild  endometritis,  it  is  likely  to  cease  under  these  meas- 
ures and  remain  away  permanently  if  the  treatment  is  continued  for  some 
months — long  enough  to  restore  the  general  health  and  the  local  tone.  If 
the  bloody  discharge  persists  in  spite  of  above  measures  continued  for  a  few 


BLOODY    DISCHARGE  1033 

weeks,  it  suggests  that  there  is  some  decided  change  in  the  endometrium.  This 
may  be  only  chronic  inflammation  or  it  may,  on  the  other  hand,  be  beginning 
malignant  disease.  In  such  a  case  the  interior  of  the  uterus  should  be  thor- 
oughly curetted  under  anesthesia  and  the  currettings  submitted  to  microscopic 
examination.  If  the  trouble  is  inflammatory,  this  is  the  most  effective  thera- 
peutic measure.  If  the  trouble  is  malignant,  the  diagnosis  is  thus  made  early, 
at  a  time  when  removal  of  the  uterus  will  probably  effect  a  cure. 

d.  Vaginal  Douches.  Douches  are  usually  given  along  with  the  three 
measures  previously  mentioned.  If  there  is  a  purulent  discharge,  a  strong 
antiseptic  is  used — for  example,  the  bichloride  douche.  If  there  is  no  decided 
purulent  discharge,  an  astringent  is  used,  such  as  alum,  or  zinc  sulphate  and 
alum. 

e.  Intrauterine  Applications.  In  some  cases  a  few  intrauterine  applica- 
tions may  be  made  for  therapeutic  and  diagnostic  effect.  Copper  sulphate 
(10%  solution)  is  the  preferable  astringent  to  use.  In  simple  hyperplasia 
or  mild  inflammation  it  tends  to  stop  the  bleeding.  In  beginning  malignant 
disease  the  bloody  discharge  persists. 

f.  Curetment.  "When  there  is  a  bloody  discharge  that  persists  off  and  on, 
in  spite  of  other  measures  employed  for  a  few  Aveeks,  then  thorough  curet- 
ment under  anesthesia  is  indicated  as  a  diagnostic  and  therapeutic  measure. 
In  cases  where  the  cervical  canal  is  wide,  or  where  it  dilates  easily  mthout 
much  pain,  some  scrapings  from  the  endometrium  may  be  obtained  in  the 
regular  office  examination  by  means  of  the  small  exploring  curet  (Fig.  100). 
If  such  scrapings  shovv  malignant  disease,  the  diagnosis  is  thus  established 
without  anesthesia.  If  the  scrapings  do  not  show  malignant  disease,  then 
curetment  under  anesthesia  is  indicated,  for  in  such  a  case  malignant  disease 
can  not  be  excluded  until  a  thorough  curetment  is  made  and  all  the  scrapings 
examined.  If  no  malignant  disease  is  found,  but  the  bleeding  recurs,  a  second 
curetment  with  examination  of  the  scrapings  is  indicated.  If  the  bleeding 
recurs  only  at  long  intervals,  repeated  curettage  may  be  employed  with  much 
benefit,  provided  malignancy  can  be  positively  excluded. 

g'.  Organo-therapy.  The  administration  of  some  of  the  organo-therapeutic 
preparations  will  be  next  in  order  (see  Chapter  xv).    If  these  also  fail, 

h.  X-ray  and  Radium  Treatment  in  almost  all  instances  Avill  promptly  lead 
to  the  complete  cessation  of  all  hemorrhage.  As  described  on  page  731,  in 
speaking  of  the  radiation  of  fibromyomata,  the  cessation  of  all  ovarian  function 
with  subsequent  atrophy  of  the  uterus  quickly  follows  the  administration  of  the 
rays.  Of  late  many  enthusiastic  reports  have  appeared  concerning  the  excel- 
lent results  of  the  application  of  radium  tubes  within  the  uterine  cavity. 

Therefore,  but  rarely  it  will  become  necessary  to  resort  to  more  radical 
operative  procedures. 

i.  Hysterectomy.  If  malignant  disease  is  present,  hysterectomy  at  once  is, 
of  course,  indicated.    If  no  malignant  disease  is  present,  but  still  the  bleeding 


1034  DISTURBANCES    OF   FUNCTION 

recurs  soon  after  curetment,  and  especially  after  repeated  curetment,  hyster- 
ectomy may  be  necessary.  It  is  clearly  indicated  where  the  uterine  wall  is 
damaged  permanently  and  to  a  serious  extent,  by  scattered  fibroid  nodules, 
by  chronic  metritis  (sclerosis)  or  by  the  condition  designated  as  ''myopathia 
hemorrhagica." 


CHAPTER  XV 

THE  INTERNAL  SECRETORY  GLANDS  IN  RELATION  TO 

GYNECOLOGY 

By  Hugo  Eheekfest,  M.D.* 

In  two  of  the  preceding  chapters  the  fact  has  been  repeatedly  mentioned  that 
the  ovary  is  possessed  of  an  internal  secretory  function  which  represents  an  im- 
portant factor  in  the  development,  growth  and  normal  function  of  the  genital 
tract. 

The  problem  of  the  function  of  the  endocrin  glands  during  the  past  decade 
has  proved  most  attractive  to  many  of  the  leading  biologists  and  physiologists 
of  the  world.  As  the  result  of  their  persistent  work,  our  knowledge  has  been 
greatly  increased.  The  importance  of  this  problem  for  the  modern  gynecologist 
is  so  generally  appreciated  that  it  seems  essential  to  reserve  a  special  chapter  in 
this  volume  for  a  thorough  discussion  of  the  relation  of  internal  gland  function 
to  gjTiecology. 

The  works  of  Gley  (The  Internal  Secretions,  1915)  and  Falta  (The  Ductless 
Glandular  Diseases,  1915)  rank  among  the  most  authoritative  and  exhaustive 
studies  of  the  entire  subject  of  internal  secretion.  Schaefer  (The  Endocrin 
Organs,  1916)  has  recently  compiled  important  facts,  many  the  product  of 
his  o"\^Ti  labor.  The  special  field  of  the  normal  and  abnormal  function  of  the 
female  genital  apparatus  under  the  influence  of  endocrin  gland  function  is 
most  interestingly  discussed  in  a  book  by  "VY.  Blair  Bell  (The  Sex  Complex, 
1916)  and  only  recently  has  been  covered  thoroughly  in  all  its  various  aspects 
in  a  symposium  prepared  by  eminent  American  investigators  for  the  1917 
meeting   of   the   American    Gynecological   Society    (Transactions   for   1917). 

]\Iuch  that  will  be  said  in  the  following  pages  must  be  duly  credited  to 
the  writings  of  these  recognized  authorities. 

HISTORICAL    FACTS 

It  is  interesting  to  note  that  the  gonads,  testicles,  and  ovaries,  were  the 
first  structures  proved,  by  experiments,  to  possess  a  marked  and  definite  in- 
fluence on  general  metabolism  and  on  the  development,  structure  and  func- 
tion of  other  organs. 

Berthold,  in  1849,  removed  the  testes  of  cockerels  and  transplanted  them' 


'Professor  of  Obstetrics  and  Gynecology,  St.  Louis  University. 

1035 


1036  THE  INTERNAL   SECRETORY   GLAXDS   IX   RELATIOX    TO    GYXECOLOGY 

into  other  parts  of  their  bodies.  He  found  that  the  sex  characteristics  per- 
sisted, and  thus,  possibly  was  the  first,  to  draw^  the  correct  deduction:  The 
testes  yield  a  product  which  acts  on  other  organs  of  the  body. 

In  1889,  BroTvn  Sequard  reported  to  the  Biologic  Society  of  Paris  the  re- 
sults of  experiments  with  the  injection  of  testicle  juice,  proving  to  his  satisfac- 
tion that  these  organs  furnish  substances,  which,  carried  through  the  blood  exert 
a  definite  influence  on  other  distant  organs.  This  marks  the  beginning  of 
organo-therapy. 

Kibbert,  in  1898,  and  later  Knauer  (1900)  experimented  on  female  ani- 
mals by  transplanting  their  ovaries  under  the  skin  and  avoiding  involution 
of  the  uterus  as  would  have  otherwise  occurred.  Halban  showed  that  in 
young  animals  transplanted  ovaries  will  exert  a  protective  iirfluence  on  the 
development  of  the  genital  apparatus. 

These  were  the  fundamental  experiments  (as  mentioned  in  Chapter  xii) 
to  prove  the  internal  secretory  function  of  the  ovary.  They  explained  satis- 
factorily the  relation  of  ovarian  function  to  such  striking  clinical  phenomena 
as  lack  of  development  of  the  genital  tract  at  the  time  of  puberty,  amenor- 
rhea or  the  ablation  symptoms  after  postoperative  artificial  menopause. 

Today,  less  as  the  result  of  definite  information,  and  more  as  the  outcome 
of  mere  speculation,  an  attempt  is  made  to  interpret  many  minor  aberrations 
in  the  physical  appearance  or  mental  behavior  of  women,  and  almost  all 
anomalies  of  sex  function  on  the  basis  of  a  deviation  in  the  internal  secretory 
activity  of  the  ovaries  or  other  glands  of  the  endocrin  system.  In  the  follow- 
ing discussion  of  the  entire  intricate  problem  an  effort  will  be  made  to  dif- 
ferentiate, as  clearly  as  is  possible,  between  proven  facts,  theory,  or  mere 
speculation. 

DEFINITION  OF  INTERNAL  SECRETION 

Material  of  a  non-morphologic  character,  which  is  passed  directly  into 
the  blood  or  lymph  from  any  tissue  or  organ  of  the  body  forms  its  internal 
secretion.  In  the  strict  meaning  of  the  term,  only  organs  which  are  not  known 
to  possess  any  other  function  than  that  of  passing  such  specific  chemical 
substances  into  the  blood  or  Ijinph,  are  ductless,  internallij  secreting,  endocrin 
glands.  Under  the  term  ductless  gland,  in  this  limited  meaning,  therefore,  are 
comprised  the  thyroid,  pajrathyroids,  suprarenal  capsules,  or  adrenals,  the 
pituitary  body,  or  hypophysis  cerebri,  the  pineal  gland,  or  epiphysis  cerebri, 
and  thymus. 

At  present,  however,  it  is  quite  evident  that  the  production  of  specific 
chemical  agents  which,  carried  through  the  blood,  influence  distant  structures 
is  not  confined  to  these  ductless  glands,  but  that  identical  active  substances  are 
also  produced  by  other  organs  obviously  serving  another  functional  purpose. 

Mering  and  ^Minkowski,  in  1889,  first  demonstrated  that  the  pancreas  has 


CHEMICAL    NATURE    OF    INTERNAL    SECRETIONS  1037 

an  internal  secretory  function,  in  addition  to  its  known  external  secretory  func- 
tion, of  producing  the  pancreatic  juice,  so  important  in  the  digestion- of  food 
material  within  the  intestinal  tract.  Pancreatic  internal  secretion  now  is 
known  to  be  essential  to  the  proper  utilization  of  carbohydrates  in  the  tissues. 

A  still  more  remarkable  example  of  a  combination  of  important  external 
and  internal  secretory  activities  in  the  same  orgau  is  supplied  by  the  generative 
glands — testicle  and  ovary. 

It  has  been  kno^^-n  from  time  immemorial — and  the  experiment  is  re- 
peated daily  for  commercial  purposes  in  thousands  of  animals,  and  is  still 
practiced  on  man  in  certain  Oriental  countries — that  the  removal  of  the  sex 
glands  in  the  young  male  usually  prevents  the  development  of  the  accessory 
sex  chracteristics. 

Eeference  already  has  been  made  to  the  fact  that  removal  of  the  ovaries 
in  the  young  female  exerts  a  profound  influence  over  the  organism  and  pre- 
vents the  appearance  of  many  of  the  female  characteristics.  In  some  cases, 
even  in  the  adult,  removal  or  atrophy  of  the  ovaries  has  been  noticed  to  lead 
to  the  development  of  male  characteristics.  In  young  mammals  removal  of 
the  ovaries  is  followed  by  arrest  of  growth  of  the  uterus,  which  effect  can  be 
prevented  by  grafting  an  ovary  from  another  animal  of  the  same  species 
into  the  peritoneum  or  elsewhere.  It  seems  clear,  therefore,  that  both  in  the 
male  and'the  female  the  effect  of  the  removal  of  the  gonads  is  due  to  the  absence 
of  a  definite  active  substance  normally  produced  by  these  glands. 

The  terms  ductless  glands,  internal  secretion  glands,  or  endocrin  organs,  as 
now  promiscuously  used,  therefore,  apply  to  a  number  of  special  organs  pos- 
sessing the  property  of  producing  biologic  substances  which,  absorbed  into  the 
blood  in  normal  amounts,  are  capable  of  exerting  a  definite  and  specific  influence 
on  distant  organs,  and  of  maintaining  the  entire  organism  at  par.  "Whenever 
their  activity  is  either  diminished  (hypof unction)  or  increased  {hyperf unction), 
they  will  cause  a  general  disturbance  in  bodily  function,  which  w411  be  more 
or  less  characteristic  of  the  special  gland  or  glands  so  involved. 

CHEMICAL  NATURE  OF  INTERNAL  SECRETIONS 

The  active  substances  produced  by  external  and  internal  secretions  seem 
essentially  different  from  each  other.  In  the  case  of  the  external  secretions 
the  active  agents  are  ahvays  of  the  nature  of  a  ferment.  They  belong  to  the 
class  of  bodies  which  are  known  as  enzyms,  i^robably  are  of  a  protein  nature 
and  readily  destroyed  by  heat  in  the  presence  of  water.  The  active  materials 
of  the  endocrin  organs,  on  the  other  hand,  are  for  the  most  part  not  ren- 
dered inert  even  by  prolonged  boiling  and  are  certainly  of  a  much  simpler 
chemical  constitution  than  enzyms.  The  active  material  of  the  adrenal  has 
been  isolated  in  a  pure  crystalline  form,  even  has  been  prepared  synthetically 
(Schaefer). 


1038  THE   INTERNAL   SECRETORY   GLANDS   IN   RELATION    TO    GYNECOLOGY 

Some  of  these  substances  act  instantly,  very  much  like  the  active  prin- 
ciples especially  of  vegetable  drugs.  Of  interest  in  relation  to  our  special  sub- 
ject in  this  respect  are  the  extracts  of  the  adrenals  and  of  the  pituitary  body. 
Other  active  agents  of  internal  secretion  operate  slowly.  The  effect  of  their 
action  becomes  apparent  only  after  a  prolonged  period  of  time.  This  latter 
class  usually  exert  a  specific  influence  upon  the  growth  and  nutrition  of  spe- 
cial organs.  They  have  been  termed  by  Gley  ''morphogenetic."  Most  im- 
portant among  them  are  the  internal  secretions  of  testicle  and  ovary. 

As  with  drugs,  some  of  the  active  principles  yielded  by  the  endocrin 
organs  act  by  stimulating  cell  function,  others  again  depress  or  actually 
inhibit  this  function.  Starling  originally  gave  to  the  stimulating  principles 
the  name  ''hormones,"  derived  from  a  Greek  word  meaning  ''to  excite." 
By  custom  this  term  now  is  commonly  applied  to  all  the  active  principles  of 
endocrin  secretion  and,  therefore,  includes  those  of  a  depressing  or  inhibiting 
character.  Various  efforts  to  replace  this  term  "hormones,"  not  entirely  cor- 
rect, by  others,  as  a  whole,  seemed  to  have  failed. 

INTERGLANDULAR  RELATION 

The  present  status  of  this  aspect  of  the  problem  of  internal  secretion  is 
described  by  Falta  as  follows:  An  immense  amount  of  work  in  recent  years 
has  been  devoted  to  the  study  of  the  reciprocal  action  of  the  ductless  glands, 
and  hypotheses  and  speculations  have  grown  luxuriantly.  It  seems  that  up 
to  the  present  we  really  know  nothing  exactly  concerning  the  intimate 
process  in  these  correlated  actions;  but  in  clinical  experience  the  existence  of 
such  an  interaction  forces  itself  unmistakably  upon  the  observer. 

To  illustrate  the  last  part  of  this  statement  but  a  few  examples  germane 
to  our  subject  may  be  cited.  At  puberty,  when  the  first  corpus  luteum  forms 
and  ovarian  function  in  its  stricter  sense  begins,  pineal  glands  and  thymus 
involute  while  coincidentally  the  thyroid  enlarges.  Premature  involution  of 
the  thymus  seems  to  cause  premature  puberty ;  i.  e.,  premature  beginning  of 
the  process  of  ovulation.  During  pregnancy,  when  ovarian  function  is  in  a 
quiescent  state,  the  hypophysis  cerebri,  among  the  endocrin  gland,  under- 
goes most  marked  changes,  while  slighter  alterations  commonly  can  be  ob- 
served also  in  the  function  of  the  adrenals,  thyroid,  parathyroids,  and  pan- 
creas. These  facts  are  known,  but  their  cause  and  their  interrelation  are  not 
fully  understood. 

It  is  assumed  that  all  the  endocrin  organs  work  harmoniously  in  form 
of  an  " interglandular  reciprocity"  or  "chemical  correlation"  as  one  system. 
The  equilibrium  of  the  entire  system  presumably  is  disturbed  by  functional 
disturbance  of  only  one  gland  of  the  system. 

Loss  of  function  in  one  gland  may  cause  another  to  hyperfunctionate  if  the 
diseased  gland  under  normal  conditions  does  exert  an  inhibitory  effect.     The 


INTERGLAXDULAR    RELATION  1039 

other  gland  then  is  supposed  to  cooperate  with  the  diseased  gland  in  making  up 
for  the  deficiency  of  the  latter  and  such  glands  are  called  synergists.  On  the 
other  hand,  if  formerly  responsible  for  a  stimulating  effect  on  another  member 
of  the  endocrin  system,  Injpo function  in  one  gland  is  supposed  to  induce  hypo- 
function  in  another  if  they  are  antagonists.  In  accord  with  this  classification  (of 
Okintschitz)  ovary  and  thyroids  seem  antagonistic,  while  the  relation  be- 
tween ovary  and  the  pituitary,  pineal  gland  or  thymus  possibly  is  synergetic. 

This  synergism'  or  antagonism  of  action  existing  between  the  various 
organs  of  the  endocrin  gland  system  Bell  has  attempted  to  express  more  con- 
cretely in  the  katabolic  or  anabolic  influence,  respectively,  exerted  by  various 
internal  secretory  structures  on  the  calcium  metabolism.  His  conclusions  con- 
cerning the  chemical  interrelation  of  all  the  endocrin  glands  in  their  ultimate 
eifect  both  on  all  functional  activities  of  the  generative  apparatus  of  woman 
and  on  the  development  of  female  physical  and  psychic  characteristics,  while 
not  firmly  proved,  in  general  certainly  are  interesting  and  stimulating 
enough  to  be  quoted  in  this  connection. 

The  essential  fact  to  be  borne  in  mind,  according  to  Bell,  is  that  femininity 
itself  is  dependent  on  all  the  internal  secretions.  It  formerly  was  thought  that 
a  woman  was  a  woman  because  of  her  ovaries  alone.  But  not  any  longer  we 
should  consider  the  gonads  as  acting  alone  in  their  influence  on  the  female 
characteristics  and  genital  functions,  except  in  regard  to  the  production  of 
ova.  The  ovaries  should  be  looked  upon  solely  as  a  part  of  the  system  to  which 
most,  if  not  all  the  endocrin  glands  belong,  and  in  which  these  other  organs  in 
relation  to  the  reproductive  functions  figure  with  as  great  importance  as  the 
ovaries  themselves. 

At  birth  we  distinguish  the  sex  of  the  child  by  the  character  of  the 
external  genitals,  which  in  normal  circumstances  correspond  Avith  the  internal 
genitals.  These  genital  features  are  generally  held  to  constitute  the  primary 
sex  characteristics.  The  secondary  characteristics,  however,  constitute  the 
sex  ensemble,  seen  not  only  with  respect  to  the  general  conformation  of  the 
body  (pelvis,  fat  distribution,  breasts,  etc.),  but  also  in  connection  with  the 
specialized  functions  peculiar  to  the  sex,  both  physical  and  psychic.  There 
are  two  stages  in  the  development  of  the  secondary  characteristics.  The  first 
stage  extends  from  birth  to  puberty.  The  development  is  slow,  the  genital 
functions  themselves  are  dormant.  At  puberty,  however,  comes  the  remarkable 
change,  physical  and  mental. 

Although  the  genitals  may  be  normal  morphologically  at  birth  (fetal 
development)  yet  they  only  become  functionally  active  at  puberty  (complete 
development)  if  the  whole  endocrin  system  is  in  perfect  harmony,  and  is 
acting  efficiently  and  normally  in  regard  to  its  sexual  function.  Thus,  thyroid 
or  pituitary  insufficiency  may  cause  the  genital  organs  to  remain  infantile. 
Diseases  of  these  structures  may  cause  retrogression  in  the  genitals,  and  even 
after  they  have  functionated  normally,  thus  causing  cessation  of  menstrua- 


1040  THE   INTERNAL    SECRETORY   GLANDS   IN    RELATION    TO    GYNECOLOGY 

tion,  sterility,  etc.  Furthermore,  it  is  believed  that  the  gonads  and  uterus  re- 
main not  fully  developed  until  the  thymus  atrophies  at  the  time  of  puberty. 

An  explanation  for  this  interrelation,  both  in  form  of  synergism  and  an- 
tagonism, possibly  is  suggested  in  the  fact  that,  according  to  the  investigations 
of  Bell,  ovaries  are  katabolic  in  regard  to  calcium  metabolism  by  promoting 
calcium  excretion,  while,  on  the  other  hand,  it  is  believed  that  the  thymus 
produces  calcium  retention,  so  essential  for  the  normal  growth  of  the  child 
up  to  puberty.  The  phenomenon  of  calcium  retention  again  becomes  char- 
acteristic late  in  life  during  the  climacteric ;  i.  e.,  after  the  cessation  of  all 
ovarian  activity. 

In  Bell's  opinion,  also  the  physical  and  mental  characteristics  come  under 
the  dominant  influence,  not  only  of  the  ovaries,  but  of  the  entire  endocrin 
system.  "The  endocrin  organs,"  Bell  writes,  ''represent  structures  in  which 
qualitative  and  ciuantitative  changes  influence  metabolism  towards  masculinity 
or  femininity,  as  the  case  may  be.  It  is  interesting  and  instructive  to  note  that 
changes  similar  to  those  occurring  in  the  pituitary  and  suprarenals  during 
pregnancy ,  which  produce  calcium  retention  for  the  benefit  of  the  fetus  ivitliouf 
producing  mascidinity  in  the  mother,  may  in  the  non-pregnant  woman  produce 
the  characteristics  of  masculinity,  and  not  so  rarely,  not  only  physical,  but  also 
masculinity  in  the  mental  processes. 

In  finally  summing  up  the  question  of  inter  glandular  relationship  to  the 
genital  tract  it  may  be  said  that  a  reciprocity  of  action  does  exist,  beyond  any 
doubt,  that  only  perfect  harmony  between  all  the  endocrin  glands  seems  to 
lead  to  normal  development  and  later  to  normal  function  of  the  generative 
apparatus  in  the  female.  At  the  present  time,  however,  our  knowledge  is 
still  too  limited  to  formulate  any  definite  statements  as  to  the  exact  mechan- 
isms of  this  correlation.  As  will  be  seen  later,  it  is  the  lack  of  definite  infor- 
mation concerning  this  feature  of  the  entire  problem  which  of  necessity  makes 
organo-therapeutic  efforts  for  the  present  chiefly  only  empirical  or  experi- 
mental. 

INFLUENCE   OF  INDIVIDUAL  ENDOCRIN   ORGANS   ON  THE 
GENITAL  APPARATUS 

Whatever  knowledge  we  have  on  this  special  question  in  the  main  has 
been  acquired  in  the  following  manner: 

a.  By  clinical  observations  in  those  cases  in  which  the  functional  activity 
of  one  of  the  internal  secretory  organs  was  altered,  either  in  form  of  hypofunc- 
tion  or  hyperfunction,  by  evident  pathologic  processes  in  the  organ. 

b.  By  clinical  observations  on  patients  in  whom  one  of  the  endocrin  organs 
had  been  removed  by  operation  for  definite  reasons. 

c.  But  chiefly,  by  experiments  on  animals  carried  out  both  in  form  of 


INFLUENCE    OF    ENDOCRIN    ORGANS    ON   GENITAL   APPARATUS  1041 

removal  of  such  organs,  or  by  injection  of  various  forms  of  extracts  made  from 
endocrin  gland  tissues. 

A  simple  reflexion  will  show  how  readily  these  three  sources  may  lead  to 
most  misleading  errors. 

The  extirpation  of  an  endocrin  organ  by  operation  or  for  the  purpose  of 
the  experiment  certainly  is  but  a  poor,  if  not  entirely  incorrect,  imitation 
of  the  rather  gradual  and  usually  incomplete  suppression  of  functional  activity 
of  this  same  structure  as  the  result  of  a  pathologic  process. 

Watery  or  ethereal  and  alcoholic  extracts,  juices  obtained  by  crushing 
and  compression  of  certain  tissues,  and  preparations  made  in  various  other 
manners,  to  be  injected  for  experimental  study,  are  supposed  to  contain  the 
specific  hormones.  It  is  obvious  that  such  so-called  extracts  not  necessarily 
contain  any  or  all  the  active  agents,  or  in  any  definite  concentration.  The 
injection  of  such  an  extract  apparently  often  means  the  parenteral  introduc- 
tion of  protein  substances  and  many  of  the  phenomena  obtained  in  such  ex- 
periments and  interpreted  as  hormone  action,  noAv  are  correctly  recognized 
as  anaphylactic  symptoms. 

It  is  now  generally  appreciated  that  definite  observations,  clearly  estab- 
lished for  one  species,  are  absolutely  incorrect  for  another  species.  It  is  this 
fact  which  explains  the  often  contradictory  results  obtained  hy  experienced 
investigators  when  the  one  was  studying,  e.  g.,  cats,  the  other  probably  guinea 
pigs  or  rabbits. 

A  striking  lack  of  discrimination  in  this  respect  has  been  shown  by  many 
clinicians.  They  have  insisted  in  the  past,  and,  unfortunately,  still  at  the 
present  time  insist,  upon  applying  to  the  human  being,  facts  established 
solely  by  animal  experiments  concerning  the  normal  or  abnormal  functional 
activity  of  this  or  that  endocrin  gland.  This  reprehensive  practice  is  respon- 
sible for  much  of  the  confusion  now  existing. 

A  serious  attempt  to  bring  order  into  this  confusion,  so  far  as  the  rela- 
tion of  each  ductless  gland  to  the  female  genital  apparatus  is  concerned,  has 
been  made  recently  in  the  symposium  prepared  for  the  1917  meeting  of  the 
American  Gynecological  Society,  already  mentioned  in  preceding  pages  (see 
Ehrenfest,  Interstate  Medical  Journal,  1917).  Some  of  the  material  presented 
in  these  most  valuable  contrilmtions  of  well-knoAvn  American  scientists  will  be 
used  for  the  following  outline  of  the  role  played  by  the  individual  endocrin 
organs  in  the  development  and  function  of  the  sex  tract  in  woman. 

1.  Ovary 

There  are  three  different  structures  in  the  ovary  which  must  be  considered 
in  relation  to  its  internal  secretory  activity:  the  follicle  apparatus,  the  corpus 
luteum,  and  the  interstitial  gland. 

The  follicle,  containing  the  ovum,  obviously  is  the  most  important  of  the 
constituents.    It  not  only  accomplishes  primarily  the  double  function  of  sup- 


1042  THE   INTERNAL   SECRETORY   GLANDS   IN   RELATION    TO    GYNECOLOGY 

plying  the  ovum  and  a  definite  internal  secretion,  but  secondarily  it  also  gives 
origin  to  two  new  structures ;  viz.,  the  corpus  luteum  and  the  interstitial  gland. 
After  rupture  of  the  mature  Graafian  follicle,  the  granulosa  cells  transform 
into  the  typical  pigmented  lutein  cells.  The  possibility,  however,  can  not  be 
entirely  excluded  that  some  of  the  theca  cells  participate  in  this  transformation. 
Obviously  only  a  very  small  percentage  of  the  thirty  thousand,  or  more. 
Graafian  follicles  of  the  newborn  female  child  actually  reach  maturity  and 
give  rise  to  corpora  lutea.  The  overwhelming  majority  degenerate  and  be- 
come atretic.  In  the  opinion  of  some  investigators  (e.  g.,  Fraenkel,  Wallart, 
and  others),  at  least  in  certain  species,  a  derivative  of  the  end  products  of  fol- 
licle degeneration  represents  the  so-called  interstitial  gland.  This  view,  how- 
ever, is  not  shared  by  others  (e.  g.,  Aschner)  who  regards  the  interstitial 
gland  of  the  ovary  a  distinct  morphologic  entity.  So  far  as  the  human  being  is 
concerned,  it  may  suffice  in  this  connection  to  state  that  the  structure  called 
interstitial  gland,  whatever  its  origin  might  be,  is  found  only  in  early  life, 
and  that  puberty  apparently  marks  the  end  of  its  existence.  Its  observation 
in  the  ovaries  of  adult  women  undeniably  constitutes  one  of  the  rarest  his- 
tologic findings. 

Based  upon  these  morphologic  premises  we,  therefore,  may  assume  that 
the  possible  internal  secretory  influence  of  the  interstitial  gland  in  woman  of 
necessity  must  be  limited  in  the  main  to  the  formative  period  of  life,  and 
that  its  effect  upon  vital  processes  after  puberty  is  not  conceivable.  It  may  not 
be  amiss  to  emphasize  here  that  the  important  studies  of  M'llroy  on  animals 
have  gone  to  show  that  the  presence  of  interstitial  gland  cells  is  necessary 
for  the  continuation  of  ovarian  function  in  transplanted  ovaries. 

The  most  important  factor,  however,  in  the  internal  secretory  function 
of  the  ovary,  as  rather  generally  conceded,  is  supplied  by  the  corpus  luteum. 
In  its  full  development  it  presents  the  characteristic  picture  of  an  endocrin 
gland  which  generally  shows  large  pale  cells  of  epithelial  character  lying 
closely  attached  to  a  rich  net-work  of  thin-walled  vessels. 

The  fundamental  experiments  and  clinical  observations  establishing  this 
function  of  the  corpus  luteum  we  owe  to  Fraenkel;  a  more  accurate  knowl- 
edge of  the  finer  mechanism  of  corpus  luteum  function,  to  the  painstaking 
investigations  of  Leo  Loeb.  Again  we  must  emphasize  that  his  findings  can 
not  be  assumed  to  be  true  for  woman.  He,  himself,  most  carefully  points 
out  the  striking  differences,  evident  in  minor  details  and  essential  features, 
between  various  species  of  animals.  Loeb's  most  important  conclusions  are 
as  follows:  Cyclic  changes  occur  in  the  ovary  and  secondarily  in  the  uterus 
and  mammary  glands.  The  primary  cyclic  changes  in  the  ovary  are  in  se- 
quence: follicle  ripening,  ovulation,  and  corpus  luteum  formation.  An  elab- 
orate, self-regulating  mechanism  controls  ovulation.  Normally  the  corpus 
luteum  inhibits  ovulation.  During  pregnancy  the  life  of  the  corpus  luteum  is 
prolonged.    Experimentally  ovulation  can  be  influenced  at  will,  accelerated  by 


INFLUENCE    OF   ENDOCRIN   ORGANS    ON   GENITAL   APPARATUS  1043 

excising  all  corpora  lutea,  or  retarded  by  producing  artificial  deciduomata. 
The  retarding  effect  of  the  corpus  luteum  is  chemical,  not  mechanical.  The 
corpus  luteum  has  a  sensitizing  effect  on  the  uterus  (endometrium).  If  the 
uterus  is  incised  or  mechanically  stimulated  during  the  time  when  the  corpus 
luteum  is  elaborating  its  growth  hormone,  a  maternal  placenta  (deciduoma) 
is  formed.  The  mechanical  stimuli,  therefore,  in  this  respect  assume  the 
function  Avhich  the  fertilized  ovum  exerts  under  normal  conditions. 

Corresponding  to  and  dependent  upon  the  cyclic  ovarian  changes  uterine 
cyclic  changes  occur.  Growth  activity  is  the  result  of  corpus  luteum  secre- 
tion. Regression  marks  the  cessation  of  this  secretion,  which  in  the  interval 
is  followed  by  a  condition  of  rest. 

It  follows  that  the  corpus  luteum  subserves  at  least  two  functions,  in- 
hibiting ovulation  and  producing  a  substance  which  causes  growth  in  the 
uterus. 

The  ovary  shows  other  non-cyclic  functions.  It  has  a  trophic  influence  on 
the  genitals  and,  either  primarily  or  secondarily  determines  the  development 
of  the  secondary  sex  characteristics.  The  ovary,  likewise,  controls  the  de- 
velopment of  the  mammary  gland.  It  exerts  a  trophic  influence  on  this 
organ  and  determines  its  normal  cycle. 

These  findings  of  Loeb  in  animals  seem  to  support  Fraenkel's  earlier 
claims,  based  partly  upon  experiments  and  partly  on  clinical  observations, 
that  the  corpus  luteum  prepares  the  endometrium  for  the  reception  of  the 
fertilized  ovum.  If  impregnation  fails  to  occur,  the  endometrium  undergoes 
retrogressive  changes  which  find  their  outward  expression  in  form  of  the 
bloody  menstrual  discharge.  Corpus  luteum  function  probably  also  is  re- 
quired for  the  integrity  of  the  implanted  ovum  during  the  first  few  weeks  of 
pregnancy.  Removal  of  the  ovary  containing  the  corpus  luteum  (or  corpora 
lutea)  of  pregnancy,  or  particularly  bilateral  oophorectomy  early  in  preg- 
nancy, both  in  the  human  and  animals,  almost  invariably  results  in  abortion. 
Corpus  luteum  function,  at  least  in  the  human,  is  not  essential  in  the  later 
normal  progress  of  pregnancy. 

Before  discussing  ovarian  function  in  general,  we  may  emphasize  once 
more  the  fact  that  there  still  exists  considerable  divergence  of  opinions  in 
regard  to  the  question  of  which  among  the  different  structures  of  the  ovary  ac- 
tually is  essential  in  the  maintenance  of  its  endocriu  activity.  As  already  men- 
tioned, M'llroy  considers  the  presence  of  interstitial  gland  cells  as  necessary. 
Others,  and  they  seem  at  the  present  time  in  the  majority,  lay  more  stress 
on  the  importance  of  the  corpus  luteum.  On  the  other  hand,  it  can  not  be 
denied  that  at  least  temporary  success  in  avoiding  the  typical  castration  symp- 
toms has  been  recorded,  both  in  the  human  and  in  animals,  even  when  the 
successfully  transplanted  piece  of  ovarian  tissue  did  not  exhibit  any  signs 
of  ovulation  or  of  the  formation  of  a  corpus  luteum.  This  latter  point  becomes 
significantly  important   in  the   classic   experiments   of   Steinach    (Ztschr.   i. 


1044  THE   INTERNAL    SECRETORY   GLANDS    IN   RELATION    TO    GYNECOLOGY 

Physiol.,  1913).  He  found  that  transplantation  of  ovarian  tissue  upon  castrated 
male  rats  is  followed  by  the  development  of  typical  female  characteristics,  such 
as  enlargement  of  the  breasts  and  changes  in  the  skeletal  structure,  although 
every  Graafian  follicle  had  become  atrophied  in  the  transplanted  ovarian  tissue. 

The  following  facts  concerning  ovarian  function  can  be  accepted  as  estab- 
lished: The  ovaries  provide  the  ova,  and  a  specific  internal  secretion,  or  pos- 
sibly secretions.  On  the  influence  of  these  specific  agents,  when  provided  in 
normal  quantity,  depend  (a)  the  development  of  the  generative  organs  from 
birth  to  puberty;  (b)  the  establishment  of  puberty  at  the  proper  time,  mani- 
festing itself  in  the  appearance  of  the  first  menstrual  flow,  and  the  develop- 
ment of  the  secondary  sex  characteristics;  (c)  the  normal  continuation  of  the 
cyclic  endometrial  changes  expressed  in  a  normal  menstrual  discharge  re- 
curring in  rather  regular  intervals;  (d)  sensitizing  of  the  endometrium  so  that 
its  mechanical  irritation  by  the  implantation  of  the  fertilized  ovum  leads  to 
the  formation  of  the  maternal  placenta;  (e)  a  certain  protection  of  the  im- 
planted ovum  in  the  earlier  stages  of  pregnancy;  and  (f)  trophic  growth 
stimulation  of  the  mammary  glands  during  pregnancy. 

Complete  absence  of  endocrin  ovarian  secretion  results  (a)  in  the  young, 
in  arrest  of  further  development  of  sex  apparatus  (infantile  genitals).  Men- 
struation fails  to  appear,  female  secondary  sex  characteristics  develop  incom- 
pletely; both  in  physical  and  mental  characteristics,  a  certain  degree  of  mas- 
culinity may  become  noticeable ;  (b)  in  the  adult,  in  cessation  of  the  established 
functional  activity  of  the  genital  apparatus  (amenorrhea,  artiflcial  menopause, 
sterility,  etc.),  with  progressive  evidences  of  retrogression  (atrophy  of  uterus 
and  breasts,  etc.),  possibly  associated  with  a  slight  change  of  certain  physical 
and  mental  characteristics  of  femininity  to  those  of  masculinity.  The  cessation 
of  established  genital  function,  especially  when  appearing  suddenly,  often  is 
followed  by  definite  disturbances  in  the  vasomotor  system  (hot  flushes,  palpi- 
tation, sweating,  etc.),  alterations  in  the  general  metabolism  (leading-  to 
adiposity  in  50  per  cent  of  the  cases)  and  indefinite  mental  changes.  The 
phenomena  of  this  latter  group  do  not  occur  constantly. 

The  evident  individual  variation  in  this  respect  once  more  forces  to  mind 
the  probable  fact  that  the  ovary  functionates  but  as  a  part  of  the  entire 
endocrin  system.  The  ovaries,  Bell  suggests,  are  concerned  in  the  temporary 
function  of  reproducing  the  species  (by  providing  ova),  and  by  their  hormones 
influence  the  general  metabolism  of  the  body  solely  to  the  benefit  of  the 
reproductive  activity  of  the  individual.  "The  differences  in  the  effects  pro- 
duced by  oophorectomy  in  women  are  largely  dependent  on  the  individual 
variations  which  we  know  to  exist  with  respect  to  the  relative  adjustment  of 
all  the  internal  secretions.  They  are  often  evident  in  the  outward  character- 
istics of  adiposity  and  thinness,  lethargy  and  brightness,  and  in  many  other 
physical  and  psychic  attributes.    It  is  clear,  therefore,  that  if  one  woman  be 


INFLUENCE    OF    ENDOCRIN    ORGANS    ON    GENITAL   APPARATUS  1045 

better  adjusted  than  another  against  the  removal  of  all  ovarian  secretion,  she 
will  show  less  the  signs  of  menopause." 

After  this  consideration  of  the  definite  and  established  effects  both  of  nor- 
mal endocrin  ovarian  activity,  and  complete  absence  of  this  activity,  we  shall 
turn  to  a  discussion  of  the  less  known,  and,  in  many  aspects,  only  hypothetic, 
results  of  anomalous  internal  ovarian  secretion  in  form  either  of  hypoactivity 
or  hyperactivity.  At  the  outset  the  fact  must  be  emphasized,  that  we  do  not 
know  any  characteristic  histologic  pictures  indicating  anomalies  of  function  in 
the  ovary.  It  is  a  fact  that  in  many  instances,  almost  as  the  rule,  even  extensive 
involvement  of  ovarian  tissue  in  pathologic  processes,  especially  new  growth,  cyst 
formations,  etc.,  does  not  lead  to  the  symptoms  usually  ascribed  to  hypofuuction. 
Only  occasionally  writers  insist  upon  an  etiologic  relation  of  the  presence  of 
small  cysts  in  the  ovaries  to  the  symptoms  of  hyperfunction. 

Hypof unction  may  be  primary  or  secondary  (Frank).  Primary  hypofuuc- 
tion is  due  to  developmental  anomalies  in  the  prepuberty  stage  and,  therefore, 
are  likely  to  be  associated  with  general  stigmas  of  maldevelopment,  especially 
in  the  skeleton.  Obviously  in  many  of  these  women,  there  can  be  discovered 
also  variations  in  the  secondary  characteristics  (anomalous  distribution  of  hair 
or  fat,  etc.),  with  certain  nervous  symptoms  indicating  instability  (especially 
of  the  vasomotor  system)  and,  of  particular  interest  to  the  gynecologist,  per- 
manent local  stigmata  of  maldevelopment  (such  as  infantile  uterus). 

Symptomatically  ovarian  hypofuuction,  therefore,  may  express  itself  in 
(a)  amenorrhea,  (b)  scanty  and  painful  menstruation,  appearing  irregularly 
and  often  at  long  intervals,  and  (c)  possibly  sterility,  encountered  usually  in 
an  asthenic  girl  with  the  stigmas  of  general  infantilism. 

Secondary  ovarian  hypofuuction  usually  occurs  in  consequence  of  diseases 
of  other  endocrin  glands  (exophthalmic  goiter,  myxedema,  acromegaly,  dis- 
trophia  adiposogenitalis,  Addison's  disease,  diabetes,  etc.).  Particularly  in 
these  diseases  the  clinical  symptoms  of  hypofuuction  of  the  ovary  often  are 
preceded  by  a  transitory  period  of  apparent  hyperfunction. 

Secondary  hypofuuction  commonly  is  the  temporary  or  permanent  result 
of  wasting  diseases  (tuberculosis,  typhoid,  etc.),  or  of  other  weakening  influ- 
ences (labor  and  subsequent  lactation).  The  general  metabolism  of  the  body 
requires  all  its  energies  to  concentrate  in  an  effort  of  combating  the  disease  or 
to  make  up  for  the  serious  loss  of  body  fluids  (milk  secretion).  The  ovary 
proves  a  most  sensitive  organ  in  reacting  to  any  general  disturbance  Avhich  de- 
presses the  equilibrium  of  normal  metabolism  of  a  Avoman  below  par  (see 
Ehreufest,  Keappearance  of  Menstruation  after  Childbirth,  Am.  Jour.  Obst 
1915). 

The  clinical  symptoms  of  hypofuuction  or  of  complete  absence  of  func- 
tion, at  present,  often  are  intentionally  produced  by  subjecting  the  ovaries  to 
the  effect  of  X-rays  or  radium.     (See  Chapter  viii.) 


1046  THE   INTERNAL   SECEETORY   GLANDS   IN   RELATION    TO    GYNECOLOGY 

Hyperfunction  may  be  also  conveniently  divided  into  a  primary  and  sec- 
ondary form. 

Primary  hyperfunction  is  a  condition  almost  characteristically  limited  to 
the  beginning  (puberty)  and  -end  (menopause)  of  the  period  of  reproductive 
activity. 

The  clinical  symptoms  consist  in  an  exaggeration  both  of  amount  and 
duration  of  the  menstrual  flow  (menorrhagia)  or  in  more  or  less  severe  uterine 
hemorrhages  occurring  in  irregular  intervals  (metrorrhagia).  In  these  cases 
the  endometrium  very  often  is  found  in  a  state  of  simple  hyperplasia  (see 
Chapter  vi),  devoid  of  any  histologic  signs  of  inflammation. 

It  has  been  suggested  that  primary  functional  hyperactivity  of  the  ovaries 
represents  the  underlying  cause  for  the  development  of  uterine  fibromyomata. 

Secondary  ovarian  hyperfunction  often  is  met  with  only  -as  a  transitory 
symptom  at  the  onset  of  disease  in  another  endocrin  gland  (mentioned  above) 
soon  followed  by  the  symptoms  of  hypofunction. 

The  investigations  by  Hitschmann  and  Adler  of  the  cyclic  changes  in  the 
endometrium  in  their  relation  to  histologic  flndings  heretofore  considered 
characteristic  of  endomentritis  have  furnished  valuable  support  for  the  con- 
tention of  preceding  investigators  that  menorrhagia  and  metrorrhagia,  com- 
monly associated  with  pelvic  inflammatory  processes  or  uterine  malpositions, 
are  not  caused  by  an  endometritis,  but,  in  fact,  are  the  expression  of  a  sec- 
ondary ovarian  hyperactivity,  the  result  of  ovarian  overstimulation  by  a  local 
active  or  passive  congestion. 

The  repeated  confirmation  of  the  work  of  Hitschmann  and  Adler  by  all 
subsequent  investigators  tends  to  prove  the  correctness  of  their  assertion,  at 
first  repudiated  as  too  radical,  that  with  the  exception  of  the  instances  of 
carcinoma  or  other  destructive  processes  in  the  endometrium,  of  uterine  polypi, 
and  of  abortions,  all  other  types  of  atypical  uterine  hemorrhage  are  due  to 
anomalies  of  endocrin  ovarian  activity. 

2.  Thyroid  Gland 

Marine  (Trans.  Am.  Gynec.  Soc,  1917)  summarizes  his  investigations  as 
follows:  "The  relation  of  the  thyroid  to  the  sex  organs  in  the  female  is  the 
most  ancient  and  classical  illustration  of  the  interrelation  of  the  function  of 
glands  Avith  internal  secretion.  Such  a  thyroid  sex  gland  relation  in  the 
female  is  recognizable  in  association  with  the  development  of  secondary  sex 
characteristics  at  puberty,  with  menstruation  and  with  ]3regnancy,  and  also  in 
the  male  Avith  puberty,  but  to  a  very  slight  degree.  During  each  of  these 
periods  the  iody  metal) olism  is  increased,  and  as  it  is  a  major  function  of  the 
thyroid  to  stimidate  oxidation  processes  in  the  tody,  it  is  prohahle  that  the 
heightened  metaholism  is  of  thyroid  origin  and  that  the  enlargement  of  the 
thyroid  at  these  times  is  the  result  of  a  true  work  hypertrophy.  This  view  is 
supported  by  the  fact  that  supplying  the  iodine-containing  hormone  artificially 


INFLUENCE    OF    ENDOCRIN    ORGANS    ON    GENITAL   APPARATUS  1047 

or  even  iodine,  from  which  the  gland  can  elaborate  its  own  hormone  in  in- 
creased amounts,  prevents  the  hypertrophy,  and  in  any  developing  hypertro- 
phy of  the  gland  the  iodine  is  reduced. ' ' 

It  is  usually  stated  that  the  thyroids  in  women  are  larger  per  unit  of  body 
weight  than  in  men.  This  in  general  is  true,  so  far  as  anatomic  statistics  can 
go,  but  it  has  misled  some  Avriters  to  imply  that  the  difference  is  inherent, 
w^hile  in  fact  it  is  acquired  and  can  be  entirely  controlled.  It  is  well  knoAvn 
that  thyroid  hyperplasia  in  form  of  the  simple  goiter  is  from  six  to  eight 
times  more  common  in  the  female  than  in  the  male  during  and  after  adoles- 
cence. Up  to  adolescence  no  difference  can  be  seen  between  the  two  sexes.  A 
similar  prevalence  of  females  can  be  noticed  among  patients  suffering  from 
Graves'  disease.  Extensive  studies  of  this  striking  fact,  however,  so  far  have 
not  yielded  any  definite  clue  to  the  exact  nature  of  thyroid  sex  gland  relation. 
It  must  be  assumed  that  the  mutual  influence  of  the  one  gland  on  the  other 
somehow  is  connected  with  alterations  in  the  iodine  component  of  general 
metabolism  since  all  the  known  physiologic  activity  of  the  thyroid  is  asso- 
ciated with  iodine. 

3.  Parathjrroid  Glands 

The  parathyroid  gland,  according  to  Voegtlin  and  Pool,  has  a  definite 
physiologic  function  which  is  still  incompletely  understood.  The  presence  of 
a  minimum  of  tissue  in  the  body  is  essential  for  life  and  for  the  continuation  of 
normal  metabolism.  No  direct  relationship,  however,  has  been  established 
between  the  parathyroids  and  the  female  sex  organs ;  no  morphologic  changes 
in  the  glands  have  been  noted  during  pregnancy ;  yet  apparently  there  is  a  con- 
nection between  the  parathyroids  and  the  sex  processes  in  the  female. 

Tetany,  the  clinical  evidence  of  parathyroid  insufficiency,  is  somewhat 
prone  to  occur  in  menstruating,  pregnant,  and  puerperal  women,  as  well  as 
patients  suffering  from  gynecologic  troubles  or  who  have  undergone  gynecolo- 
gic operations.  Pregnancy  puts  an  extra  strain  on  the  function  of  the  para- 
thyroids, as  evidenced  by  the  appearance  of  tetany  during  this  period  in  par- 
tially parathyi'oidectomized  animals.  Tetany  also  has  been  observed  during 
lactation  in  animals  with  parathyroid  insufficiency.  Interruption  of  lactation 
was  followed  by  recovery. 

The  function  of  the  parathyroids  is  apparently  closely  connected  with 
calcium  metabolism.  There  is  reason  to  believe  that  pregnancy  tetany  and 
lactation  tetany  are  associated  with  calcium  deficiency.  Latent  tetany,  or  a 
subtetanic  condition,  is  much  more  common  an  puerperal  Avomen  than  is 
usually  assumed;  according  to  Seitz  and  Thierry  it  occurs  in  ten  per  cent  of 
all  women  during  the  last  months  of  pregnancy,  or  in  the  course  of  childbirth. 

The  offspring  of  partially  parathyroidectomized  animals  exhibit  a  marked 
increase  in  nerve  irritability.  Tetany  in  newborn  infants  of  tetanic  mothers 
is  usually  fatal  within  a  short  time  after  birth.    In  the  treatment  of  tetany  of 


1048  THE   INTERNAL    SECRETORT    GLANDS   IN   RELATION    TO    GYNECOLOGY 

pregnant  women  tlie  administration  of  calcium  in  large  doses  is  followed  by 
beneficial  results  in  the  great  majority  of  cases. 

Experimental  facts  do  not  support  the  theory  that  eclampsia  is  due  to 
hypoparathyroidism. 

4.  Pituitary  Gland 

The  status  of  our  present  knowledge  concerning  the  influence  of  the 
pituitary  gland  on  sex  processes  in  the  female  is  concisely  presented  in  the 
following  quotations  from  a  paper  by  Goetsch. 

Abundant  experimental  evidence  and  numerous  observations  on  pituitary 
disturbances  in  the  human  subject  have  clearl}-  established  the  close  inter- 
relation in  function  between  the  pituitary  and  sex  glands.  Overfunction  of 
the  pituitary  anterior  lobe  is  associated  with  overactivity  of  the  sex  glands. 
"If  it  were  possible  to  examine  the  sex  glands  in  the  early  stages  of  gigantism 
and  acromegaly  one  would,  in  all  probability,  find  histologic  evidences  of  very 
active  spermatogenesis  in  the  male  and  abundant  ovulation  in  the  female." 
The  pituitary  gland  undergoes  a  kind  of  involution  from  the  hyperactive  stage 
in  acromegaly,  and  the  early  increased  libido  and  hyperactivity  of  sexual 
function  changes  into  loss  of  libido  and  even  impotence  in  the  male,  and 
leads  to  cessation  of  menstruation  and  sterility  in  the  female  (secondary 
ovarian  hyperfunction  and  subsequent  hypofunction).  Deficiency  in  pituitary 
secretion  is  followed  by  underdevelopment  and  aplasia  of  the  genital  tract  in 
the  young  (primary  ovarian  hypofunction)  and  by  sexual  inactivity  and 
retrogression  in  the  adult. 

Primary  alterations  in  the  function  of  the  sex  glands,  as  in  pregnancy 
and  after  castration,  are  followed  by  pituitary  hypertrophy  and  hyperplasia. 

The  specific  action  of  posterior  lobe  extract  (pituitrin,  pituitary  liquid, 
etc.),  upon  the  smooth  musculature  of  the  uterus  and  bowels  has  led  to  the 
wide  usage  of  this  drug  in  obstetric  practice  and  in  the  treatment  of  in- 
testinal paresis  following  abdominal  and  pelvic  operations. 

5.  Adrenal  Bodies 

From  a  thorough  study  of  this  question  by  Vincent  we  learn  the  follow- 
ing facts:  The  adrenal  cortex  or  adrenal  proper  is  developed  from  the 
germ  epithelium,  and  the  evidence  now  is  strongly  in  favor  of  the  view  that  it 
has  certain  important  functions  in  connection  with  the  development  and 
growth  of  the  sex  organs.  There  is  a  considerable  amount  of  clinical  evi- 
dence that  tumors  of  the  adrenal  cortex  are  frequently  associated  with  sex 
abnormalities.  Adrenal  hypernephromata  in  children — more  commonly  seen 
in  females — are  almost  invariably  characterized  by  precocious  growth  of  the 
body  generally  and  of  the  sexual  organs  in  particular.  This  same  evidence 
also  favors  the  view  that  when  cortical  tumors  occur  ii\  the  female,  an  accen- 


INFLUENCE    OF    ENDOCRIN    ORGANS    ON    GENITAL   APPARATUS  10-1:9 

tuatioii  of  male  secondary  characteristics  develops,  and  simultaneously  a 
hypoplastic  condition  of  the  internal  genitals  supervenes  (Glynn,  Quart.  Jour. 
Med.,  1918).    During  breeding  and  pregnancy  the  cortex  enlarges. 

6.  Thymus 

Pappenheimer,  "who  did  much  important  experimental  Avork  on  thymus 
function,  expresses  himself  rather  sceptically  concerning  the  positive  informa- 
tion at  present  available. 

The  vigorous  research,  he  writes,  that  has  been  expended  on  the  thymus 
gland  during  the  past  fcAV  years,  has  not,  on  the  whole,  been  very  fruitful. 
That  the  thymus  serves  an  important  function  especially  in  the  growing  or- 
ganism and  has  a  constant  relation  to  the  development  of  the  sex  organs  can 
not  be  doubted.  But  there  is  a  striking  conflict  as  to  facts  and  interpretation. 
It  is  impossible  to  draw  any  far-reaching  conclusions  as  to  the  importance  of  the 
thymus  in  relation  to  the  disorders  of  the  female  genital  tract.  The  earlier 
work  of  Klose  and  his  successors  adduced  a  massive  array  of  experimental 
work  in  favor  of  the  view  that  the  thymus  is  an  essential  organ  exerting  a 
controlling  influence  upon  growth  and  bone  formation.  A  number,  of  other 
investigators,  however,  including  Pappenheimer,  have  failed  to  substantiate 
these  findings.  "The  fundamental  problems  of  thymus  physiology  remain  un- 
solved, and  the  established  facts  concerning  normal  and  abnormal  structure  of 
the  gland,  are  not  such  as  lend  themselves  to  clinical  application." 

7.  Pineal  Gland 

In  a  study  of  the  histories  of  forty  cases  of  pineal  tumors  collected  from 
literature,  Marburg  attributes  to  the  condition  the  following  characteristics: 
General  sjTuptoms  of  intracranial  pressure,  if  an  internal  hydrocephalus  has 
developed;  localized  sjonptoms,  if  the  tumor  compresses  adjacent  structures 
(quadrigeminate  bodies,  cerebellum,  etc.),  and  constitutiofial  symptoms,  if  pineal 
gland  function  is  deranged.  This  constitutional  syndrome  consists  of  (a)  early 
sexual  maturity,  evidenced  in  large  sex  organs,  pubic  hair,  general  body  hair, 
early  change  in  voice;  (b)  precocious  mental  development,  and  (c)  general 
body  overgrowth.  . 

On  the  other  hand,  McCord  emphasizes,  the  literature  contains  records 
of  many  cases  of  pineal  tumors  which,  though  appearing  before  puberty,  did 
not  show  any  signs  of  precocity  of  development  that  are  so  striking  in  a  few 
selected  cases.  "A  study  of  the  clinical  material  reveals  how  little  considera- 
tion has  been  given  to  the  possibility  of  pluriglandular  involvement."  Experi- 
mental work  so  far  has  yielded  only  rather  contradictory  results.  Evidences 
at  present  available  that  link  the  pineal  body  with  a  glandular  function  are 
very  indefinite  and  "doubt  is  frequently  expressed  that  the  pineal  body  is 
more  than  a  functional  vestige  of  what  once,  in  earlier  evolutional  stages,  was 
a  functionating  eye." 


1050  THE   INTERNAL   SECRETORY   GLANDS   IN   RELATION    TO    GYNECOLOGY 

The  inference  is  allowable  that  the  pineal  body  is  an  internal  secretory 
gland  of  minor  significance  in  the  general  activities  of  the  endocrin  system. 
Because  of  its  involution  at  puberty,  constitutional  symptoms  of  pineal  pathol- 
ogy presumably  are  confined  to  prepuberal  years. 

8.  Pancreas 

According  to  Carlson  there  does  not  exist  at  the  present  time  any  evidence 
of  any  specific  relations  of  the  endocrin  functions  of  the  pancreas  and  the 
gonads,  male  or  female, .  or  to  menstruation,  jjregnancy  or  lactation.  True 
diabetes,  induced  in  animals  after  conception,  leads  to  abortion.  Absolute 
diabetes  renders  conception  impossible.  Partial  diabetes  under  careful  die- 
tary control  permits  of  normal  sex  life  in  women  (menstruation,  normal  preg- 
nancy, normal  child,  lactation),  and  pregnancy  under  such  conditions  does 
not  aggravate' the  diabetes.  But  in  the  absence  of  such  dietary  control, 
pregnancy  will  aggravate  the  mother's  diabetes;  and  uncontrolled  diabetes 
in  the  mother  is  extremely  injurious  to  the  fetus.  There  is  some  evidence  that 
in  late  stages  of  pregnancy  the  fetal  pancreas  may  functionate  also  for  the 
mother. 

9.  Placenta 

While  not  coming  strictly  within  the  limits  of  this  discussion  of  the  rela- 
tion of  internal  secretions  to  gynecology,  it  may  be  permissible,  for  the  sake 
of  completeness,  to  refer  here  briefly  to  the  question  whether  the  placenta 
can  be  regarded  as  a  gland  with  an  internal  secretion. 

This  question  has  been  answered  in  the  affirmative  for  the  first  time  by 
Halban.  He  based  his  theory  chiefly  on  clinical  facts.  Frank  (Surg.,  Gynec. 
and  Obst.,  1915),  recently  has  fully  confirmed  the  experiments  of  Herrmann 
which  establish  definitely  the  fact  that. the  placenta  exerts  a  specific  action 
on  uterus  and  breasts.  Placental  extracts,  especially  the  lipoid  fraction,  rap- 
idly induce  hyperplasia  of  the  uterus  and  breasts,  in  castrated  and  in  non- 
castrated  animals. 

Interesting  is  the  indisputable  observation  that  the  substance  extracted 
from  placental  tissue  in  its  physical,  chemical  and  biologic  properties  appears 
to  be  identical  with  a  similar  substance  obtained  from  the  corpus  luteum.  This 
apparent  identity  leaves  the  question  of  specific  placental  hormones  still 
open,  since  there  remains  the  possibility  that  the  placenta  acts  merely  as  a 
storage  reservoir  for  corpus  luteum  secretion  during  the  latter  part  of 
pregnancy, 

GYNECOLOGIC  ANOMALIES  DUE  TO  DISTURBED  ENDOCRIN 

GLAND  FUNCTION 

A  consideration  of  gynecologic  anomalies,  or,  more  correctly  expressed, 
of  certain  gynecologic  findings  and  symptoms  in  their  etiologic  relation  to 


DISTURBED   ENDOCRIN    GLAND   FUNCTION  1051 

functional  disturbances  of  the  endocrin  system,  of  necessity,  requires  repeti- 
tion of  much  that  has  been  stated  in  the  preceding  pages.  A  rearrangement  of 
certain  facts,  however,  in  accord  with  conditions  commonly  dealt  with  by  the 
gynecologist  will  render  all  available  knowledge  concerning  this  interrelation 
more  accessible  for  ready  application  in  actual  Avork. 

A  note  of  warning  must  be  sounded  first.  By  common  usage  Ave  differ- 
entiate diseases  into  organic  and  functional.  The  first  group  represents  con- 
ditions due  to  definite  structural  alterations,  Avhile  the  latter  group  is  meant 
to  comprise  the  diseases  of  obscure  pathology  (see  Chapter  xiv).  In  the  light 
of  our  present  knowledge,  furthered  chiefly  by  physiologic  and  biochemic  re- 
search work,  such  a  sharp  distinction  is  no  longer  possible.  While  not  exhibit- 
ing any  pathognomonic  tissue  lesions,  many  of  the  so-called  "functional"  dis- 
eases, nevertheless,  have  a  pathology,  now  well  understood.  Progress  in  medicine 
has  established  the  fact  that  other  causes  besides  pathologic  tissue  changes  may 
be  the  definite  etiologic  factors  of  disease.  Applying  this  truism  to  gynecologic 
diseases  it  must  be  admitted  that  certain  anomalies  of  function  in  the  female 
genital  apparatus  are  the  direct  or  indirect  result  of  disturbed  internal  secre- 
tory activity  of  the  ovary  or  of  other  glands  of  the  endocrin  system.  But  this 
advance  of  information  still  is  limited  only  to  certain  functional  anomalies.  The 
rather  widespread  attempt  to  explain  practically  all  gynecologic  diseases,  with  the 
sole  exception  of  those  obviously  due  to  infection  or  traumatism,  on  the  basis  of 
a  hypof unction,  hyperf unction  or  ' '  dysfunction ' '  of  one  or  more  of  the  endocrin 
glands  is  unjustifiable  and  unfortunate.  A  gynecologic  condition  can  and  sJiould 
he  regarded  as  the  result  of  anomalous  internal  secretion  only  after  the  most  care- 
ful examination  and  study  of  the  case  has  failed  to  reveal  any  other  possible 
cause. 

1.  Maldevelopment  of  Internal  Genitals 

Infantilism  is  generally  looked  upon  as  the  result  of  a  disturbance  in  the 
endocrin  system.  This  arrest  of  development  may  be  noticeable  in  all  parts  of 
the  body  (universal  infantilism)  or  be  limited  to  certain  parts  (partial  infan- 
tilism). Therefore,  a  rudimentary,  infantile  or  puerile  uterus  often  is  found 
associated  with  other  stigmas  of  infantilism,  especially  in  the  skeleton.  If  the 
maldevelopment  is  limited  to  the  internal  genitals  and  the  ovaries  are  small 
and  atrophic,  a  deficiency  in  ovarian  function  commonly  is  suspected  as  its 
primary  cause.  It  must  be  remembered,  however,  that  this  deficiency  can  not 
properly  be  laid  at  the  doors  of  the  corpus  luteum,  since  this  organ  obviously 
can  exert  its  influence  only  after  puberty  has  been  established.  In  the  pre- 
puberal  stage  of  development  an  internal  secretion  could  be  supplied  by  the 
ovary  only  through  the  interstitial  gland.  In  a  considerable  number  of  these 
cases,  however,  the  ovaries  apparently  are  normal.  Then  the  underdevelop- 
ment of  the  uterus  obviously  can  be  but  part  of  the  ''general  hypoplastic 
condition."    And  it  is  this  fact  which  raises  the  logical  question  whether  in 


1052  THE   INTERNAL   SECRETOEY   GLANDS   IN   RELATION    TO    GYNECOLOGY 

cases  of  infantile  uterus  with  small  ovaries  also  the  hypoplastic  ovaries  are 
but  an  incidental  manifestation  of  the  general  hypoplasia. 

In  the  opinion  of  some  writers,  enteroptosis,  an  abnormal  mobility  of  all 
abdominal  organs,  is  a  stigma  of  infantilism,  and,  therefore,  congenital  and 
developmental  malpositions  of  the  uterus  (anteflexion,  retroflexion,  prociden- 
tia, etc.)  only  the  indirect  expression  of  a  hypoplastic  condition  or  the  remote 
result  of  disturbed  endocrin  gland  function. 

Pronounced  alterations  especially  in  thyroid  and  pituitary  function  un- 
deniably interfere  wdth  normal  development  of  the  genitals  from  birth  to 
puberty,  presumably  as  the  result  of  suppression  or  insufficiency  in  the  pro- 
duction of  hormones  which  normally  further  growth  (stimulate  calcium  reten- 
tion according  to  Bell). 

In  the  diagnosis  of  maldevelopment  or  malposition  of  the  uterus  it  must  not 
be  forgotten  that  such  anomalies  may  be  caused  by  local  inflammatory  pro- 
cesses (tubercular,  gonorrheal  or  other  infections)  not  uncommonly  observed 
even  in  young  girls. 

2.  Uterine  Atrophy 

Uterine  atrophy  is  the  result  of  retrograde  changes  (involution)  in  the 
fully  developed  uterus.  It,  therefore,  must  be  the  result  of  deflciency  or  com- 
plete disappearance  of  speciflc  growth  stimuli,  up  to  that  time  in  sufficient 
quantity  supplied  to  the  uterus  probablj;^  by  the  cyclic  formation  of  the  corpus 
luteum.  The  uterus  and  usually  with  it  the  other  parts  of  the  entire  genital 
system,  including  the  breasts,  become  atrophic  when  ovulation  ceases  or  when 
all  ovarian  tissue  is  removed  (castration)  or  destroyed  by  the  effect  of  radium 
or  X-rays.  In  other  words,  progressive  involution  of  the  uterus  in  its  flnal 
analysis  is  the  result  of  the  same  etiologic  factors  which,  outside  of  preg- 
nancy, lead  to  gradual  or  complete  suppression  of  ovulation ;  i.  e.,  in  its  out- 
ward expression,  to  gradual  or  complete  cessation  of  the  menstrual  flow.  A 
more  detailed  discussion  of  these  etiologic  factors  will  be  given  in  later  para- 
graphs dealing  with  menstrual  disturbances. 

3.  Delayed  Puberty 

Puberty  is  characterized  by  the  full,  i.  e.,  normal  development  of  both  the 
primary  and  secondary  sex  characteristics  (see  Chapter  xiv).  These  physical 
and  mental  signs  of  maturity  are  accompanied  by  the  evidences  of  beginning 
reproductive  activity — the  appearance  of,  the  flrst  menstrual  flow  induced  by 
ovulation  (corpus  luteum  function).  Puberty,  more  exactly,  is  reached  when 
Graafian  follicles  begin  to  pass  through  their  complete  cycle :  maturation,  rup- 
ture, discharge  of  ovum,  formation  of  corpus  luteum,  change  to  corpus  albi- 
cans, complete  resorption. .  Thus  the  beginning  of  ovulation  (puberty)  at 
the  proper  age  is  dependent,  rather  indefinitely,  upon  some  influences  of  race, 


DISTURBED    EXDOCRIX    GLAXD    FUNCTION  1053 

climate,  heredity,  social  condition,  mental  and  sexual  stimulation,  etc.,  and, 
more  definitely,  upon  the  general  physical  condition  of  the  girl. 

A  poor  physical  condition  is  the  most  common  obvious  cause  of  delayed 
puberty.  This  gynecologic  anomaly,  therefore,  relatively  often  is  seen  in 
poorly  nourished,  anemic  and  debilitated  (as  the  result  of  the  wasting  diseases) 
girls. 

In  a  small  group  of  cases,  however,  late  pubescence  evidently  is  only  part 
of  general  maldevelopment  (infantilism),  or  is  found  associated  with  marked 
disease  of  one  or  more  glands  of  the  endoerin  system.  As  one  of  the  more 
common  observations  the  delay  of  puberty  in  cretins  may  be  cited. 

The  inference  seems  permissible  that  in  these  patients  a  deficiency  in 
thyroid  secretion  is  responsible  for  a  lack  of  hormones  which  are  essential  in 
the  proper  stimulation  of  the  ovaries. 

The  theory  (based  upon  the  animal  experiments  of  Klose  and  others) 
that  the  thymus  has  an  inhibitory  influence  on  ovarian  function,  and  that, 
therefore,  ovarian  function  can  not  begin  before  thymus  function  is  ended,  has 
been  greatly  weakened  by  recent  investigations. 

4.  Precocious  Puberty 

The  beginning  of  ovarian  function  (puberty)  at  an  unusually  early  age 
almost  invariably  is  due  to  disease  of  endoerin  organs. 

Adrenal  hypernephromata  in  children,  more  frequently  observed  in  girls 
than  in  boys,  are  characterized  by  a  precocious  growth  of  the  body  generally, 
and  of  the  sexual  organs  in  particular.  Also  in  cases  of  pineal  tumors  early 
sexual  maturity  has  been  pointed  out  by  Marburg  as  one  of  the  typical 
symptoms.  McCord,  however,  has  shown  that  literature  contains  records  of 
many  cases  of  pineal  tumors  which,  though  appearing  before  maturity,  did 
not  exhibit  any  signs  of  precocity. 

A  careful  study  of  the  recorded  cases  of  precocious  puberty  in  girls  has 
convinced  Bell  that  true  feminine  sexual  precocity  appears  to  be  produced 
only  by  tumors  or  hyperplasia  in  the  ovaries.  Changes  in  the  suprarenal  cor- 
tex, pineal,  and  the  pituitary,  resembling  those  which  in  boys  invariably 
produce  precocity,  in  girls  rather  tend  to  produce  the  stigmas  of  masculinity. 

5.  Anomalies  of  the  Menstrual  Flow 

The  stimulus  for  the  menstrual  flow  undeniably  is  supplied  by  the  ovaries. 
In  the  absence  of  functionating  ovarian  tissue  menstruation  is  impossible. 
The  exact  mechanism  of  the  relation  of  the  ovary  to  the  menstrual  flow  seem- 
ingly is  established  by  the  discovery  that  corpus  luteum  secretion  results  in 
growth  activity  in  the  uterus,  while  regressive  signs  (necrosis,  hemorrhage) 
characterize  the  cessation  of  corpus  luteum  secretion  at  each  cycle.  Granted 
this  relation,  logically  two  deductions  seem  justifiable:     First,  that  the  regu- 


1054  THE   INTERNAL   SECRETORY    GLANDS    IN    RELATION    TO    GYNECOLOGY 

larity  of  menstruation  is  dependent  upon  tlie  regularity  of  ovulation;  and 
secondly,  that  pathologic  scarcity  of  menstrual  flow,  oligomenorrhea,  will  be  the 
result  of  a  deficient  supply  of  stimulating  hormones  coming  from  the  ovary 
(hypof unction),  amenorrhea  undeniably  being  the  result  of  complete  cessa- 
tion of  ovarian  function. 

Oligomenorrhea  is  commonly,  and  continued  amenorrhea  almost  always, 
associated  with  a  corresponding  decrease  in  the  size  of  the  uterus.  The  ex- 
planation of  this  coincidence  formerly  was  that  the  primary  progressive 
atrophy  of  the  uterus  secondarily  leads  to  the  gradual  reduction  of  the  men- 
strual flow.  In  the  light  of  present  knowledge  it  seems  more  plausible  that 
both  phenomena  are  conjointly  due  to  an  increasing  deficiency  of  internal 
secretory  function  of  the  ovary. 

The  common  clinical  experience  that  wasting  diseases  (such  as  tuber- 
culosis, typhoid,  etc.),  even  in  the  earlier  stage,  or  the  loss  of  important  body 
fiuids  (e.  g.,  prolonged  suppuration,  lactation,  etc.)  often  lead  to  a  lessening 
or  entire  suppression  of  menstruation,  must  be  explained  by  a  marked  sensitive- 
ness of  the  ovary  to  all  severe  disturbances  of  the  general  metabolism.  This 
same  explanation  may  hold  true  for  identical  changes  in  menstruation  com- 
monly observed  in  patients  suffering  from  exophthalmic  goiter,  myxedema, 
acromegaly,  Addison's  disease,  diabetes,  etc.  In  some  of  these  conditions, 
however,  the  characteristic  symptom  complex  is  such  as  to  suggest  strongly 
that  the  evident  functional  disturbance  in  one  endocrin  gland  directly  affects 
the  internal  secretory  activity  of  the  ovary.  The  fact,  e.  g.,  seems  fairly  well 
established  that  hypofunction  of  the  pituitary  after  iDuberty  is  promptly  fol- 
lowed by  a  marked  tendency  to  general  accumulation  of  fat  typically  asso- 
ciated with  a  decrease  or  cessation  of  the  menstrual  flow,  a  condition  knoT^Ti  as 
' '  dystrophia  adiposogenitalis. ' ' 

But  it  can  easily  be  demonstrated  that  our  general  knowledge  concern- 
ing such  an  interrelation  still  is  most  unsatisfactory.  To  cite  a  striking  ex- 
ample :  In  case  of  myxedema,  i.  e.,  in  a  condition  of  definite  hypothjToidism, 
amenorrhea  is  rather  the  rule.  On  the  other  hand,  it  has  been  stated  by  Kocher 
that  women,  on  whom  too  radical  a  goiter  operation  has  been  performed,  will 
suffer  from  menorrhagia.  This  observation  was  typical  enough  to  induce  him 
to  term  the  condition  "menorrhagia  thyreopriva. "  Thus  thjrroid  deficiency 
apparently  leads  to  both  amenorrhea  and  menorrhagia,  and  in  the  same  way 
both  the  evidences  of  ovarian  hypofunction  and  hyperfunction  are  seen  in 
cases  of  definite  hyperthyroidism  (exophthalmic  goiter). 

In  view  of  such  striking  discrepancy  of  opinions  in  regard  to  certain  in- 
fluences actuating  ovarian  hypofunction,  we  must,  for  the  present,  be  con- 
tent with  the  more  definite  conclusion  that  a  decrease  in  OA'arian  function  leads 
to  a  corresponding  decrease  in  menstrual  flow.  This  decrease  may  manifest 
itself  in  a  scant  floAv  of  short  duration  or  in  a  gradual  lengthening  of  the  in- 
termenstrual interval.    While  the  first  phenomenon  is  entirely  in  harmony  with 


DISTURBED   ENDOCRIN    GLAND   PUXCTION  1055 

the  conception  of  ovarian  function  as  now  understood,  the  latter  alteration 
of  the  regular  menstrual  cycle  necessarily  will  remain  obscure  until  we  know 
more  about  the  causes  of  that  striking  rhytmicity  evident  in  other  organ  func- 
tions  (heart,  respiration,  intestinal  peristalsis,  etc.). 

6.  Metrorrhagia 

In  an  inverse  manner,  however,  we  are  not  justified  in  deducing  that  an 
increase  of  internal  secretory  activity  of  the  ovary  necessarily  accounts  for 
every  increase  in  the  menstrual  discharge.  Menorrhagia  and  metrorrhagia 
might  be  dependent  upon  local  conditions.  This,  indeed,  heretofore  has  been 
the  prevailing  opinion.  Textbooks  still  cite  menorrhagia  and  metrorrhagia  as 
the  classical  symptoms  of  endometritis,  infectious  processes  in  uterus  or  its 
adnexa,  fibromyoma,  or  retroflexion.  A  radical  change  of  these  time-honored 
conceptions  was  forced  upon  the  gynecologist  chiefly  by  two  discoveries,  now 
firmly  established  by  many  expert  investigators:  (a)  The  histologic  picture  of 
the  so-called  glandular  endometritis  in  fact  only  shows  the  endometrium  in 
its  premenstrual  cycle;  (b)  Pathologic  hemorrhages  from  the  uterus  are  satis- 
factorily explained  by  histologic  findings  (evidences  of  ruptured  or  destroyed 
capillaries,  blood  vessels,  etc.)  only  in  cases  of  abortion,  carcinoma,  destructive 
processes  in  the  uterus,  and  uterine  polypi.  This  second  fact  evolved  chiefly 
from  the  thorough  study  of  a  class  of  cases  variously  termed  as  chronic  metri- 
tis, uterine  apoplexy,  uncontrollable  metrorrhagia,  myopathia  hemorrhagica, 
etc.  Before  X-rays  and  radium  were  successfully  employed  in  the  treatment  of 
these  cases,  hysterectomy  often  had  to  be  resorted  to  as  the  only  method  of 
coping  with  the  repeated  and  sometimes  incessant  loss  of  blood.  In  this 
manner  much  valuable  material  was  obtained  for  careful  histologic  research  in 
regard  to  the  causes  of  pathologic  uterine  hemorrhages.  An  insufficient  amount 
of  musculature  (uterine  insufficiency),  a  pathologic  increase  in  connective  tis- 
sue (as  the  result  of  chronic  inflammation),  or  a  lack  of  the  required  amount 
of  elastic  tissue  in  the  uterine  wall  (developmental  defect),  sclerotic  changes 
in  the  blood  vessels  of  the  myometrium  in  turn  were  advanced  as  the  etiologic 
lesions,  because  the  endometrium  itself  in  most  of  these  uteri  was  found  to  be 
normal,  often  atrophic  and  only  occasionally  hyperplastic.  But  none  of 
these  findings  in  the  myometrium  was  constant  enough  to  prove  acceptable  as 
a  truly  satisfactory  explanation  for  this  type  of  hemorrhage.  Coincidentally 
a  better  understanding  had  developed  concerning  the  actual  relation  of  ova- 
rian function  to  the  physiologic  discharge  of  blood  from  the  uterus  (menstrua- 
tion), and  then  logically  the  conviction  began  to  gain  ground  that,  if  these 
abnormal  uterine  hemorrhages  are  not  likely  to  be  caused  by  tissue  lesions 
either  in  myometrium  or  endometrium,  they  might,  in  all  probability,  be  due 
to  ovarian  hyperactivity  and  thus  represent  the  manifestation  of  uterine 
hyperstimulation.  Of  considerable  weight  in  these  conclusions  concerning  an 
interrelation  of  anomalous  ovarian  to  anomalous  uterine  function,  of  neces- 


1056  THE   INTERNAL   SECRETORY   GLANDS   IN   RELATION    TO    GYNECOLOGY 

sity,  proved  the  common  observation,  that,  almost  typically,  disturbances  of  men- 
struation coincide  with  the  beginning  (puberty)  and  the  end  (menopause)  of 
ovarian  functional  activity.  Here  again  a  great  deal  of  material,  supplied  for 
laboratory  study  by  curettage,  definitely  established  the  fact  that  in  these  cases 
the  endometrium  usually  is  onlj^  slightly  hyperplastic  or  normal. 

Approximately  in  this  manner  the  iDresent  rather  prevalent  view  has  de- 
veloped that  with  but  a  few  definite  exceptions  (abortion,  destructive  processes, 
uterine  polypi)  possibly  all  other  abnormal  uterine  hemorrhages  are  due  to 
ovarian  hyperfunction.  In  cases  of  inflammatory  and  infectious  processes,  new 
growth,  masturbation,  etc.,  it  is  an  active  hyperemia;  in  eases  of  malposition, 
heart  lesions,  etc.,  a  passive  hyperemia  which  leads  to  the  causative  pathologic 
ovarian  overstimulation. 

Of  late  this  theory  has  been  greatly  strengthened  by  the  satisfactory  and 
often  excellent  results  obtained  with  the  use  of  radium  and  X-rays.  The  fact 
is  firmly  established  that  these  rays  primarily  affect  the  ovary.  The  beneficial 
effect  of  the  rays,  therefore,  in  the  treatment  of  metrorrhagia  (also  in  cases 
of  fibroids)  undeniably  is  obtained  only  indirectly  by  way  of  a  changed 
ovarian  function. 

A  disturbance  of  ovarian  functiou  rather  than  a  uterine  pathology  sug- 
gests itself  as  the  immediate  cause  of  the  common  disturbance  of  menstruation 
in  patients  suffering  from  disease  of  an  endocrin  gland.  While  there  are  evi- 
dent exceptions  to  the  rule,  in  general,  in  exophthalmic  goiter,  acromegaly, 
etc.,  the  hyperfunction  of  the  diseased  gland  at  first  is  accompanied  by  menor- 
rhagia  or  metrorrhagia,  which  gradually  gives  way  to  the  evidences  of  ova- 
rian hypofunction  or  complete  cessation  of  all  ovarian  activity  in  form  of  oli- 
gomenorrhea or  definite  menopause  with  permanent  atrophy  of  the  uterus. 

It  seems  most  interesting  and  suggestive  that  also  in  patients  to  whom 
radium  or  X-rays  are  administered  for  the  purpose  of  obtaining  a  reduction  or 
cessation  of  ovarian  internal  secretory  activity  the  final  amenorrhea  almost  as 
a  rule  is  preceded  by  a  period  of  free  hemorrhages. 

7.  Sterility- 
It  is  perfectly  obvious  that  any  condition  which  results  in  complete  and 
permanent  cessation  of  ovarian  function  (ovulation)  necessarily  must  include 
sterility  as  one  of  its  final  sequelae. 

The  not  uncommon  symptom  complex:  delayed  puberty,  dysmenorrhea, 
sterility,  and  uterus  of  infantile  or  puerile  type,  often  is  found  in  association 
with  stigmas  of  general  infantilism.  This  fact  establishes  another,  though  in- 
direct, relation  between  the  endocrin  system  and  sterility.  In  these  instances 
both  the  dysmenorrhea  and  sterility  are  more  reasonably  explained  by  me- 
chanical obstacles  offered  for  the  passage  of  menstrual  blood  and  spermatozoids 
by  the  long,  narrow,  and  often  sharply  bent  cervical  canal  which  is  typical  of 
the  underdeveloped  uterus. 


THERAPY  1057 

Clinical  experience  shows  that  some  cases  of  supposed  sterility  with 
occasional  long  interval  menstruations  (six  to  seven  weeks)  actually  repre- 
sent peculiar  instances  of  habitual  abortions.  In  the  light  of  the  recognized 
fact  that  corpus  luteum  secretion  is  essential,  not  only  for  the  process  of 
nidation,  but  also  for  the  early  protection  of  the  implanted  ovum,  a  relation 
of  habitual  abortion,  if  not  otherwise  explained,  to  anomalous  function  of  the 
corpus  luteum  might  be  suspected. 

Eeference  must  be  made  in  this  connection  to  the  not  unusual  observation 
of  impregnation  in  the  course  of  a  temporary  state  of  amenorrhea.  This 
apparently  paradox  occurrence  can  be  explained  in  two  ways:  (a)  A  uterus, 
which  has  become  markedly  atrophic  as  the  result  of  continued  cessation  of 
ovulation,  (e.  g.,  during  lactation)  is  anatomically  unfit  to  react  in  form  of  a 
menstrual  discharge  to  the  growth  stimulation  of  the  first  corpus  luteum; 
or  (b)  The  very  first  ovum  discharged  by  the  reestablished  ovulation  process  be- 
comes immediately  fertilized.  The  endometrium  sensitized  by  the  first  corpus 
luteum  has  no  opportunity  to  break  down  but  transforms  into  maternal 
placenta. 

The  claims  made  by  some  writers  that  also  dysmenorrhea  of  the  non- 
obstructive type  and  the  molimina  of  early  pregnancy  are  caused  by  hypofunc- 
tion  of  the  corpus  luteum  are  entirely  hypothetical.  Certain  facts  (large 
size  of  corpus  luteum,  its  acknowledged  importance  in  nidation  process,  etc.) 
rather  indicate  a  state  of  hyperactivity  early  in  pregnancy.  On  the  other 
hand,  e.  g.,  in  the  cases  of  dysmenorrhea  membranacea,  the  evident  exaggera- 
tion of  endometrial  processes  would  more  logically  suggest  ovarian  hyper- 
activity than  hypoactivity. 

THERAPY 

Though  still  decidedly  limited  in  its  scope,  information  at  present  avail- 
able concerning  the  role  played  by  functional  disturbances  of  the  ovary  and 
other  endocrin  glands  in  the  etiology  of  gynecologic  anomalies,  demands 
definite  changes  in  our  conception  of  the  rationale  of  some  of  the  methods  of 
treatment  customarily  used  in  gynecologic  practice. 

a.  The  therapeutic  value  of  certain  procedures  lecomes  doubtful.  For 
instance:  If  the  endometrium  itself  is  not  responsible  for  the  virginal  menor- 
rhagia  or  the  climacteric  metrorrhagia,  local  applications  of  caustics  or  curet- 
tage must  be  considered  improper  procedures.  Curettage  in  these  conditions 
remains  justifiable  only  if  abortion  or  a  uterine  polypus  is  suspected,  or  if  it 
seems  desirable  to  study  the  endometrium  histologically  for  diagnostic  pur- 
poses (suspected  malignancy,  etc.).  Everyday  experience  has  amply  demon- 
strated that  only  exceptionally  permanent  results  are  obtained  even  with 
repeated  curetments  in  this  tjq^e  of  uterine  hemorrhage. 

b.  Tlie  acknowledged  effectiveness  of  certain  therapeutic  methods  must  he 


1058  THE   INTERNAL   SECRETORY   GLANDS   IN   RELATION    TO    GYNECOLOGY 

explained  in  a  different  maimer.  For  instance :  Correction  of  a  uterine  malpo- 
sition relieves  an  associated  metrorrhagia,  not  by  establishing  better  circulatory 
conditions  in  the  uterus,  but  by  eliminating  a  pathologic  irritation  of  the 
ovaries  existing  as  the  result  of  pressure,  or  of  pulling  adhesions  which  incite 
the  ovary  to  hyperfunction. 

Hot  douches,  exercise,  pelvic  massage,  an  intrauterine  stem  pessary,  etc., 
do  not  directly  stimulate  to  further  growth  the  small  uterus,  arrested  in  its 
full  development,  but  probably  only  incite  the  ovary  to  an  increased  activity 
in  supplying  the  deficient  growth  hormone  to  the  uterus. 

c.  It  could  he  reasonably  expected  that  a  deficiency  in  ovarian  hormones 
tvoidd  he  counteracted  hy  the  administration  of  ovarian  extracts,  or  that  ovarian 
function  coidd  he  stimulated  and  retarded,  respectively,  hy  the  hormones  ex- 
tracted from  certain  other  glands  of  the  endocrin  system. 

Within  the  scope  of  this  chapter,  devoted  only  to  the  internal  secretion 
problem,  a  consideration  of  gynecologic  therapy  properly  must  be  limited  to  a 
discussion  of  only  those  methods  of  treatment  which  are  likely  to  stimulate 
the  hypoactive,  or  to  depress  the  hyperactive  ovary.  It  has  been  shown  in  the 
preceding  pages  that  the  anomalies  of  development  and  function  in  the  female 
genital  tract,  in  so  far  as  they  depend  upon  anomalies  of  internal  secretion, 
more  directly  are  the  result  solely  of  disturbed  ovarian  function.  The  latter, 
both  in  its  hypoactive  and  hyperactive  form,  is  dependent  upon  either  (a)  a 
local  pelvic  pathology,  (b)  impaired  general  health,  or  (c)  an  interference 
with  the  normal,  harmonious  interaction  of  all  the  glands  of  the  endocrin 
system  as  the  result  of  the  removal  or  anomalous  function  of  one  of  the 
glands. 

From  this  point  of  view  it  seems  practicable  to  consider  all  therapeutic 
procedures  available  for  combating  ovarian  hypofunction  or  hyperfunction 
under  the  following  three  headings: 

1.  Local  Treatment  of  Pelvic  Pathology 

The  typical  symptoms  of  hypofunction  (oligomenorrhea,  long  interval 
menstruation,  amenorrhea)  are  rarely  observed  in  association  with  acquired 
and  non-congenital  pelvic  lesions.  Even  in  extensive  involvement  of  the 
ovaries  by  new  growths,  menstruation  does  not  necessarily  become  scanter. 

Much  more  commonly  are  seen  the  evidences  of  ovarian  hyperfunction, 
especially  in  the  presence  of  inflammatory  processes,  uterine  malpositions, 
fibromyomata,  etc.  A  menorrhagia  or  metrorrhagia  in  these  conditions  often 
appears  as  the  one  predominant  sjonptom  which  necessitates  interference.  Out- 
side of  hysterectomy  or  bilateral  oophorectomy  its  relief  in  general  will  be  de- 
pendent upon  the  degree  to  which  operative  or  conservative  methods  of  treat- 
ment in  the  individual  case  succeed  in  eliminating  further  ovarian  irritation, 
existing  as  the  result  of  inflammation,  infiltration,  pressure,  adhesions,  pelvic 
congestion,  etc.     The  value  of  curettage  in  this  connection  is  limited  to  the  re- 


THERAPY  1059 

moval  of  an  endometrium,  probably  hyperplastic,  which  will  be  restored  in  a 
histologically  more  normal  form  only,  if  coincidentally  ovarian  hyperactivity  is 
effectively  combated  by  other  therapeutic  measures. 

In  most  instances  of  ovarian  hyperactivity  a  complete  cessation  of  all 
function  can  be  obtained  by  the  use  of  radium  and  X-rays.  The  expert  with 
proper  equipment  often  will  succeed  by  means  of  these  rays  to  reduce  the 
abnormally  increased  function  exactly  to  the  extent  as  to  to  render  it  normal. 

Literature  contains  records  of  satisfactory  cures  after  partial  resection 
of  small  cystic  degenerated  ovaries  in  instances  of  abnormal  uterine  bleeding, 
apparently  not  caused  by  any  recognizable  uterine  lesions.  The  theory  of  a 
relation  of  small  cystic  degeneration  to  ovarian  hyperfunction,  based  upon  a 
few  clinical  observations  of  this  sort,  is  entirely  too  problematic  to  justify 
a  recommendation  of  ovarian  resection  as  an  appropriate  therapeutic  pro- 
cedure in  cases  of  so-called  "functional"  menorrhagia  or  metrorrhagia. 

2.  Constitutional  Treatment 

Ovarian  hypofunction  is  so  evidently  associated  with  impaired  general 
health  that  but  little  need  be  said  concerning  the  advantages  of  general  dietet- 
ic, hygienic  and  tonic  measures  in  the  treatment  of  oligomenorrhea  or  tem- 
porary amenorrhea.  A  reduction  or  suppression  of  the  menstrual  flow  often 
appears  as  one  of  the  first  manifest  symptoms  of  serious  disease,  and  it,  there- 
fore, should  be  the  rule  for  every  physician,  when  confronted  with  this  symp- 
tom, to  search  carefully  for  tuberculosis,  syphilis,  diabetes,  nephritis,  etc. 
Improvement  in  the  general  condition  of  these  patients  invariably  will  cor- 
rect the  disturbed  menstrual  function. 

The  signs  of  ovarian  hyperfunction  in  cases  of  cardiac  lesions,  usually 
disappear  promptly  when  compensation  is  restored,  and  circulatory  conditions 
in  the  pelvis  become  normal. 

Evidences  of  ovarian  hyperfunction  coincident  with  impaired  general 
health  are  commonly  seen  in  the  earlier  stages  of  diseases  of  endocrin  glands. 
They  do  not  require  special  treatment  because,  as  a  rule,  they  gradually  dis- 
appear, giving  way  to  the  signs  of  ovarian  hypofunction. 

3.  Organo-Therapy 

Indiscriminate  and  overenthusiastic  practical  application  of  facts,  labo- 
riously ascertained  in  the  laboratory  or  at  the  postmortem  table,  is  likely  to 
discredit  scientific  research.  Far-reaching  and  usually  incorrect  deductions 
are  often  drawn  by  clinicians  who  consider  the  specific  efficacy  of  a  cer- 
tain remedy  as  established,  because  in  a  number  of  instances  its  administra- 
tion is  followed  by  apparent  improvement  of  the  patient's  condition.  Many 
of  the  erroneous  theories  and  attractive  hypotheses  thus  promulgated  by 
clinicians,  require  many  years  of  most  exact  and  complex  laboratory  study  to 


1060  THE   INTERNAL    SECRETORY    GLANDS    IN   RELATION    TO    GYNECOLOGY 

establish  their  fallacy,  and  to  reinstate  scientific  truth,  carelessly  and  un 
wittingly  obscured  by  them.  This  occurrence  is  well  known  to  the  student 
of  the  history  of  medicine.  Once  again  one  can  easily  recognize  this  phe 
nomenon  by  comparing  the  literature  presented  by  phj^siologists  and  bio- 
chemists concerning  internal  secretions,  with  the  numberless  articles  record- 
ing in  medical  journals  the  satisfactory  and  often  marvelous  results  of 
organo-therapy. 

The  waste  of  the  slaughterhouse  of  yesterday,  todaj^  has  become  one  of  th 
most  valuable  by-products  of  the  packing  industry.  Packing  houses  of  thi, 
country  produce  and  advertise,  extensively  and  most  extravagantly,  the  various 
organo-therapeutic  preparations.  They  follow  the  accepted  standards  of  suc- 
cessful advertising.  The  profession,  it  would  seem,  falls  an  easy  victim  tc 
their  exaggerated  claims. 

The  fact  is  scientifically  established  that  certain  organs,  by  an  internal 
secretion,  produce  potent  biochemic  agents.  The  conclusion  is  logical,  and 
wxU  corroborated  by  some  scientific  evidence,  that  the  introduction  of  these 
agents  into  the  organism  will  alleviate  or  fully  counterbalance  the  effects  of  a 
deficiency  or  complete  absence  of  such  substances. 

The  practical  realization  of  such  an  ideal  type  of  specific  medication, 
however,  necessarily  must  be  dependent  upon  a  few  essential  requirements. 
The  administered  substance  must  be  chemically  and  biologically  identical  with 
the  one  that  is  missing  and  must  be  replaced.  In  case  of  deficient  organ  func- 
tion the  administered  substance  must  contain  all  the  hormones  normally  sup- 
plied by  this  organ.  It  must  be  available  in  a  chemically  pure  form,  and  in  a 
standardized  strength  to  permit  exact  dosage. 

If  we  compare  these  essential  requirements  of  organo-therapy  wdth  the 
actual  facts,  we  find:  Only  adrenalin  so  far  has  been  isolated  in  pure  form. 
Adrenalin,  however,  represents  only  one,  quickly  acting,  hormone,  supplied 
by  the  adrenal  cortex  and  surely  does  not  replace  all  functional  activity  of 
this  organ.  In  a  similar  way  pituitrin,  pituitary  extract,  etc.,  contain  only  a 
promptly  acting  hormone  with  a  purely  local  effect,  extracted  from  the  pos- 
terior lobe  of  the  pituitary  body.  Only  of  certain  products  prepared  from 
the  thyroid  we  know  definitely  that  they  can  counteract  successfully  all  the 
symptoms  due  to  deficient  activity  of  this  organ. 

Considering  in  particular  the  various  ovarian  preparations,  at  present 
advocated  and  marketed,  we  must  remember  the  still  unsolved  question 
whether  the  potent  substances  are  supplied  by  the  interstitial  glands,  or  the 
follicle  apparatus,  or  particularly  by  the  corpus  luteum.  The  recommenda- 
tions made  by  the  various  writers  vary  between  the  administration  in  form  of 
the  dried  powder  of  the  entire  ovary,  of  corpus  luteum  alone,  or  of  ovarian  sub- 
stance from  which  all  corpus  luteum  tissue  had  been  removed.  There  is  great 
divergence  of  opinions  as  to  the  comparative  efficacy  of  all  these  preparations, 


THERAPY  1061 

rhether  made  from  the  ovaries  of  pregnant  or  of  non-pregnant  animals,  or 
n^liether  the  material  is  obtained  from  coats,  pigs,  or  sheep,  etc. 

From  a  practical  point  of  view  the  problem  of  ovarian  preparations  be- 
omes  still  more  complex  because  many  of  the  commercial  preparations  are 
".upposed  to  supply  the  isolated  active  principles  in  form  of  an  extract.    Somo 
•f  these  extracts  are  aqueous,  others  alcoholic  or  ethereal.    Painstaking  labora- 
ory  investigations  as  yet  have  not  solved  the  problem  of  successful  extraction 
-f  all  the  active  substances  of  endocrin  glands.     Preparations  as  furnished  to 
he  physician,  as  a  rule,  do  not  indicate  this  particular  feature  of  their  produc- 
tion.    It  can  not  be  surprising,  therefore,  that  medical  literature  reveals  a 
triking  dissension  of  views  concerning  the  particular  effectiveness  of  the  one 
"^r  the  other  remedy.     It,  furthermore,  is  obvious  that  these  preparations  are 
not  employed  in  any  known  dosage  because  they  are  not  and  can  not  be 
standardized.    Easily  comparable  to  the  common  practice  of  the  patent  medi- 
cine manufacturer  of  former  days,  the  strength   of  such  extracts   often  is 
changed  without  proper  announcement  to  the  profession.     This  practice  is 
reprehensible  and  distinctly  dangerous,  at  least  in  the  case  of  such  potent 
extracts  as  those  obtained  from  the  posterior  lobe  of  the  pituitary.    There  can 
not  be  any  doubt  that  a  uterine  rupture  during  labor  occasionally  has  been 
caused  unwittingly  by  a  physician  who  did  not  know  that  the  extract  of  the 
one  manufacturer  is  made  from  double  the  amount  of  tissue  of  that  used  by 
another;  or  that  the  same  concern  now  is  furnishing  a  so-called  20  per  cent 
solution  instead  of  the  former  10  per  cent  solution  without  indicating  this 
change  on  the  label  of  the  ampoule  in  which  the  preparation  is  marketed. 

Organo-therapy  in  its  present  status  of  development  obviously  does  not 
comply  with  the  demands  enumerated  above,  which  are  essential  for  the  reali- 
zation of  the  ideal  of  specific  therapy. 

Appreciating  these  facts  one  can  not  be  surprised  to  read  what  Robert  T. 
Frank,  a  recognized  experimenter,  only  recently  wrote:  *' Little,  if  any,  ad- 
vance in  organo-therapy  is  to  be  recorded  in  the  last  years.  The  normal  num- 
ber of  reports  on  the  use  of  corpus  luteum  extracts  have  appeared  in  the  litera- 
ture. All  those  commercial  extracts  (these  were  the  extracts  which  were 
employed  in  the  clinical  articles  reported)  which  the  writer  has  examined  have 
proved  inactive  biologically,  using  the  growth  effect  exerted  on  the  rabbit 
uterus  as  a  test.  No  further  reports  on  the  general  pharmacologic  activity  of 
corpus  luteum  are  on  hand." 

The  pessimistic  attitude  evidenced  in  these  preceding  pages  concerning 
organo-therapy,  as  advocated  and  practiced  today,  must  not  be  misinterpreted. 
Certain  definite  and  good  results  in  the  treatment  of  gynecologic  disturbances, 
particularly  with  the  ovarian  extracts,  can  not  be  denied ;  but  the  iDraetitioner, 
and  especially  the  student  of  medicine,  must  be  warned  emphatically  against 
the   common  suggestion  that  the   commercial   preparations   actually  replace 


1062  THE   INTERNAL   SECRETORY   GLANDS   IN   RELATION    TO    GYNECOLOGY 

substances  missing  in  the  organism  as  the  result  of  deficient  secretory  activity 
of  the  ovary  or  other  endocrin  glands. 

Specific  diagnostic  reactions  and  specific  therapeutic  remedies  always  have 
been  the  ideal  desiderata  of  clinical  medicine.  These  ideals  so  far  have  not 
been  realized  in  the  case  of  gynecologic  organo-therapy.  Koehler  (Zentralbl. 
f.  Gynak.,  1915),  treated  three  series  of  eases  of  amenorrhea:  The  first  with 
extract  of  ovary  and  corpus  luteum,  the  second  with  extract  of  hypophysis 
on  account  of  its  supposed  stimulating  effect  on  the  ovary,  and  the  third 
series  with  enter oglandol,  an  extract  prepared  from  the  small  intestines, 
which  hardly  could  be  expected  to  have  any  specific  effect  on  the  ovary.  The 
results  obtained  in  all  three  groups  were  approximately  the  same.  Such  tests, 
and  they  have  been  made  in  a  similar  manner  in  other  gynecologic  anomalies, 
must  raise  serious  doubt  concerning  the  specificity  of  such  organ  extracts. 
Are  we  not  going  through  the  same  disappointment  in  organo-therapy  that  we 
have  but  recently  experienced  with  the  supposedly  specific  vaccine  therapy  of 
"Wright,  or  the  specific  reactions  for  certain  enzyms  devised  by  Abderhalden? 
The  action  of  these  organ  extracts,  if  they  prove  effective  at  all,  more  likely 
might  be  due  to  some  chemical  combinations  contained  in  organ  extracts  in 
general,  which  possibly  belong  into  the  group  of  the  amines  (Koehler). 

After  this  consideration  of  the  pharmacologic  aspect  of  organo-therapeutic 
remedies  In  general  it  Avill  be  comparatively  simple  to  present  a  few  details 
concerning  commercial  products  available  for  the  treatment  of  gynecologic 
diseases  or  anomalies. 

Ovarian  Preparations.  Desiccated  powder  of  ovarian  tissue  (entire 
gland),  or  of  corpus  luteum  alone.  Ovarian  extracts  in  liquid  form,  or  in  com- 
pressed tablets.     Corpus  luteum  extract  in  liquid  form  for  hypodermic  use,  etc. 

The  desiccated  powders  must  be  fresh  and  kept  in  a  cool  place  because 
they  are  subject  to  decomposition.  They  can  be  prescribed  in  any  desired 
doses  and  usually  are  given  in  gelatine  capsules  on  account  of  their  disagree- 
able taste  and  particularly  odor.  It  seems  that  as  a  whole  they  prove  more 
effective  than  the  compressed  tablets.  When  given  by  mouth,  the  potency  of 
such  organic  substances  may  be  seriously  impaired  on  their  way  through  the 
gastro-intestinal  tract  through  the  influence  of  digestion.  Their  pharmacologic 
effect  obviously  is  dependent  upon  the  degree  to  which  they  are  actually  re- 
sorbed  into  the  blood  in  chemically  unchanged  form. 

The  liquid  preparations  for  hypodermic  use  in  this  respect  offer  an  ad- 
vantage, which  in  practice,  hoAvever,  seems  more  than  counteracted  by  the  fact 
that  as  "extracts"  they  probably  do  not  contain  all  the  active  substances  of 
the  gland,  as  the  entire  organ  in  pulverized  form  is  more  likely  to  do. 

It  seems  almost  the  routine  to  give  the  various  preparations  by  mouth  in 
five-grain  doses  three  times  a  day,  and  hypodermic  injections  of  the  standard 
one  cubic  centimeter  ampoules  every  other  or  third  day.     There  are  no  dan- 


THERAPY  *  1063 

gerous  results  known  of  overdoses,  though  patients  occasionally  will  complain 
of  gastric  discomfort  or  headache. 

All  ovarian  preparations  still  are  used  rather  indiscriminately  in  practi- 
cally all  gynecologic  anomalies.  Literature  undeniably  contains  many  rec- 
ords of  satisfactory  and  brilliant  results.  But  if  we  could  trust  these  reports, 
corpus  luteum  will  successfully  increase  the  menstrual  flow  in  cases  of  oligo- 
menorrhea with  the  same  certainty  with  which  it  reduces,  in  the  experience 
of  other  reporters,  the  profuse  bleeding  to  a  normal  flow  in  cases  of  menor- 
rhagia.  According  to  literature  corpus  luteum  proves  equally  effective  in 
starting  menstruation  in  the  amenorrhoic  girl  and  in  stopping  metrorrhagia 
near  the  menopause.  The  literature  is  contradictory  and  bewildering,  be- 
cause most  of  the  reports  are  based  on  inexact  clinical  observations  made 
on  a  small  number  of  cases. 

All  that  can  be  said  definitely  concerning  the  therapeutic  value  of 
ovarian  preparations  is  the  following:  Powder  of  the  fresh  desiccated,  entire 
ovary  seems  the  most  effective  of  the  various  commercial  products.  Ovarian 
preparations  prove  most  valuable  for  the  relief  of  certain  symptoms  associated 
both  with  the  natural  and  artificial  menopause,  chiefly  those  evidenced  in  a 
disturbed  vasomotor  function  (hot  flushes,  attacks  of  profuse  sweating,  cold 
extremities,  palpitations,  etc.)  and  also  in  certain  psychic  phenomena  which 
often  indirectly  are  dependent  upon  these  circulatory  disturbances.  In  cases 
of  kraurosis  vulvae,  a  circulatory-trophic  affection  of  the  vulvar  skin,  the 
annoying  itching  occasionally  is  greatly  relieved  by  ovarian  preparations. 
The  good  results  sometimes  obtained  in  cases  of  amenorrhea  and  oligomenor- 
rhea are  not  convincing,  since  in  these  patients,  as  a  rule,  organo-therapy  is 
combined  with  general  hygienic-dietetic  treatment.  In  many  instances  in 
which  striking  improvement  promptly  follows  the  administration  of  ovarian 
substance,  the  beneflcial  effect  of  strong  suggestion  should  not  be  under- 
estimated. Such  unusual  remedies  hardly  ever  are  given  to  patients  without 
a  great  deal  of  explanation  regarding  their  peculiar  modus  operandi  and  their 
probable  effect.  Every  experienced'  gynecologist  knows  that  gynecologic  pa- 
tients are  unusually  susceptible  to  suggestion  of  every  kind. 

The  hope  is  justified  that  improvement  in  the  methods  of  the  preparation 
of  ovarian  extracts  will  ultimately  lead  to  a  corresponding  improvement  in  the 
results  obtained  with  their  administration. 

Thyroid  Gland  Preparations.  It  has  been  stated  above  that  of  all  the 
commercial  organo-therapeutic  remedies  only  the  thyroid  extract  actually  can 
replace  the  deficient  or  absent  gland  secretions.  The  use  of  this  extract, 
therefore,  is  clearly  indicated  in  all  instances  of  functional  anomalies  of  the 
female  genital  apparatus  which  evidently  are  due  to  hypothyroidism.  Unfor- 
tunately, however,  as  mentioned  in  preceding  pages,  hypothyroidism  may 
cause  amenorrhea,  e.  g.,  in  cases  of  myxedema,  and,  on  the  other  hand,  may 
result  in  profuse  menorrhagia,  e.  g.,  after  too  radical  thyroidectomy.     There- 


1064  THE   INTERNAL    SECRETORY    GLANDS    IN    RELATION    TO    GYNECOLOGY 

fore,  both  amenorrhea  and  metrorrhagia  can  be  properly  treated  with  thy- 
roid extract  if  first  the  fact  is  definitely  established  that  the  underlying 
cause  is  a  true  deficiency  in  thyroid  secretions.  This  may  well  serve  as  a 
good  illustration  of  the  intricacy  of  discriminative  organo-therapy  and  the 
absolute  necessity  of  exact  diagnosis. 

Pituitaiy  Gland  Preparations.  Extracts  prepared  from  the  posterior 
lohe  contain  a  quickly  acting  hormone  which  exerts  a  specific  stimulating  effect 
on  smooth  musculature.  In  gynecologic  practice  they  are  employed  after  opera- 
tions to  overcome  paretic  conditions  of  the  bladder  or  intestines.  In  cases  of  un- 
avoidable or  incomplete  abortion  administration  of  the  extract  in  small  doses, 
given  in  intervals  of  from  one  to  two  hours,  occasionally  effects  the  complete 
expulsion  of  the  uterine  contents  and  then  stops  the  uterine  hemorrhage,  thus 
obviating  operative  interference. 

Extracts  of  the  anterior  lohe  will  sometimes  benefit  clinical  states  depend- 
ent upon  primary  pituitary  disease,  showing  sexual  disturbances  in  form  of 
irregular  menstruation,  amenorrhea,  or  sterility.  In  such  cases  after  the  use 
of  anterior  lobe  extract  menstruation  and  sexual  libido  have  returned  even  when 
they  had  been  absent  for  considerable  time.  Of  late  the  suggestion  has  been 
made  by  various  writers  to  combine  the  extract  of  the  anterior  lobe  or  of  the 
entire  pituitary  gland  with  ovarian  extract  and  also  with  thyroid  extract  in 
cases  of  genital  aplasia,  especially  when  associated  with  general  adiposity 
(dystrophia  adiposogenitalis). 

Pancreas  Preparations.  Functional  disturbances  in  the  genital  sphere 
are  not  uncommonly  seen  in  diabetic  women.  This  combination  might  be 
only  accidental,  or  in  some  instances  seems  due  to  a  disturbance  of  the  normal 
endocrin  gland  interaction.  These  cases  at  the  present  time  are  not  amenable 
to  organo-therapeutic  efforts.  According  to  the  positive  statement  of  Carl- 
son there  does  not  exist  any  proof  that  any  extract  of  the  pancreas  so  far 
prepared  has  increased  the  power  of  a  diabetic  animal  or  patient  to  oxidize 
sugar. 

Mammary  Gland  Preparations.  There  has  never  been  any  evidence  ad- 
duced that  the  mammary  gland  is  an  organ  possessed  of  an  internal  secre- 
tion. Nevertheless  we  find  in  literature  records  of  good  results  obtained 
with  mammary  extracts  in  uterine  hemorrhages.  In  view  of  the  fact  that 
there  are  so  many  drugs  available,  which  are  decidedly  more  reliable  in  the 
relief  of  this  condition,  it  does  not  seem  justifiable  to  advocate  the  use  of  a 
remedy  of  such  doubtful  value  in  the  treatment  of  pathologic  uterine  bleeding. 


CHAPTER  XVI 

INVASION  OF  THE  PERITONEAL  CAVITY 

For  the  Treatment  of  Gynecologic  Diseases 

In  the  treatment  of  certain  gynecologic  affections  it  is  necessary  to  invade 
the  peritoneal  cavity.  This  invasion  of  the  great  peritoneal  sac  in  the  center 
of  the  body  necessarily  carries  Avith  it  much  risk  to  the  patient.  In  the  pre- 
antiseptic  days  the  mortality  Avas  great — so  great  that  the  operation  Avas  but 
rarely  resorted  to.  By  modern  antiseptic  and  aseptic  methods,  hoAA^ever,  the 
mortality  has  been  reduced  to  a  very  small  per  cent.  But  though  the  mortality 
of  the  operation  is  small,  Ave  must  not  forget  that  there  is  a  mortality  due 
directly  to  the  operation. 

The  danger  varies  much  in  different  cases,  depending  on  the  particular 
form  of  disease  present  and  on  the  condition  of  the  patient  at  the  time  of 
operation — but  there  is  some  danger  in  CA'ery  case.  Attention  must  be  called 
to  this  because  some  physicians  seem  prone  to  OA^erlook,  or  at  least  fail  to  give 
proper  Aveight  to  the  fact,  that  occasionally  a  patient,  Avith  everything  appar- 
ently favorable,  Avill  die,  and  no  one  can  promise  any  patient  absolutely  that 
she  Avill  survive.  One  may  say,  in  a  faA'^orable  case,  that  the  risk  is  very  slight 
and  that  in  all  probability  the  patient  Avill  go  through  the  operation  and  con- 
valescence Avithout  trouble.  But  though  the  risk  is  slight,  it  is  nevertheless  a 
risk,  and  the  patient  or  her  friends  must  so  understand  it.  Such  necessary 
explanation  to  the  patient  or  her  relatiA^es  is  made  AAdth  much  better  grace 
before  operation  than  afterAv^arcl. 

The  peritoneal  cavity  may  be  readily  entered  in  tAvo  Avays — by  incision 
through  the  anterior  abdominal  AA^all  (abdominal  section)  or  by  incision  through 
the  A^aginal  Avail  (A^aginal  section). 

ABDOMINAL  SECTION 

Abdominal  section  is  incision  into  the  peritoneal  cavity  through  the  ab- 
dominal Avail.  This  is  knoAvn  as  ''celiotomy"  and  as  "laparotomy,"  and  as 
' '  suprapubic  section. ' '  All  these  terms  refer  simj)ly  to  the  incision  through  the 
abdominal  Avail  into  the  peritoneal  cavity  and  not  to  the  subsequent  operative 
manipulations  carried  out  Avithin  the  cavity. 

The  incision  may  be  located  at  any  part  of  the  Avail — in  the  median  line  or 
laterally.  The  direction  of  the  incision  may  be  longitudinal  or  transverse  or 
oblique,  or  a  combination  of  these  directions. 

1065 


1066  INVASION    OF    THE   PERITONEAL    CAVITY 

There  is  usually  some  additional  operative  procedure  carried  out  after  the 
peritoneal  cavity  is  opened,  and  this  additional  procedure  frequently  gives  the 
name  to  the  whole  operation— for  example,  ovariotomy  (abdominal  section  with 
removal  of  an  ovary  or  an  ovarian  tumor),  myomectomy  (abdominal  section 
with  removal  of  a  fibromyoma  of  the  uterus),  abdominal  hysterectomy  (abdom- 
inal section  with  removal  of  the  uterus). 

INDICATIONS 

For  Abdominal  Section 
The  most  common  indications  for  abdominal  section  in  gynecologic  work 
are  as  follows : 

1.  Ovarian  tumors. 

2.  Broad  ligament  tumors. 

3.  Uterine  fibromyomata  with  serious  symptoms  not  yielding  to 

minor  measures.  The  abdominal  operations  in  these  cases  are 
myomectomy,  supravaginal  hysterectomy,  and  total  abdominal 
hysterectomy. 

4.  Cancer  of  the  uterus  (total  abdominal  hysterectomy). 

5.  Extrauterine  pregnancy. 

6.  Acute  pelvic  inflammation  which  spreads  in  spit©  of  other  meas- 

ures and  threatens  life. 

7.  Chronic  pelvic  inflammation  with  a  collection  of  pus  high  in  the 
pelvis,  as  in  pyosalpinx. 

8.  Chronic  pelvic  inflammation  with  a  large  amount  of  exudate 
and  persistent  troublesome  symptoms. 

9.  Chronic  pelvic  inflammation  without  decided  exudate,  if  every- 
thing else  fails  to  relieve  the  pelvic  distress. 

10.  Pelvic  tuberculosis,  if  other  measures  fail  to  produce  decided 
improvement. 

11.  Adherent  retrodisplacement   of  uterus   or  persistent  prolapse, 

causing  troublesome  symptoms  and  not  yielding  to  less  danger- 
ous measures. 

12.  Obscure  or  doubtful  pelvic  disease  which,  in  spite  of  other 
measures,  threatens  the  patient  with  death  or  "with  chronic 
invalidism  (exploratory  abdominal  section). 

CONTRAINDICATIONS 

The  more  common  contraindications  to  abdominal  section  are : 

1.  Marked  nephritis,  especially  chronic  interstitial  nephritis. 

2.  Diabetes  mellitus. 

3.  Inoperable  cancer  or  advanced  pulmonary  tuberculosis, 


ABDOMINAL    SECTION 


1067 


4.  Any  clironic  disease,  general  or  local,  causing  marked  weakness 

and  lessening  the  patient's  resistance. 

5.  Acute  disease  that  may  be  aggravated  by  the  operation. 

6.  Dermatitis  within  the  operative  field. 

All  these  contraindications  are  of  course  only  relative.  There  may  arise 
circumstances  demanding  the  operation  at  once  in  spite  of  contraindications — 
that  is,  circumstances  in  which  the  danger  of  delay  would  be  greater  than  the 
danger  of  immediate  operation.  But  when  the  case  is  not  one  of  extreme 
urgency,  the  operation  should  be  postponed  until  the  complicating  condition 
can  be  corrected  and  the  patient  placed  in  better  condition. 

Pregnancy  increases  the  danger  of  abdominal  section  very  decidedly,  but 
it  is  not  often  a  contraindication  for  the  reason  that  the  disease  requiring 
operation  (for  example,  a  large  tumor  or  an  abscess)  precludes  the  full  de- 
velopment of  the  fetus  or  makes  the  dangers  from  advancing  pregnancy 
greater  than  those  from  immediate  operation. 

DANGERS 

Of  Abdominal  Section 

The  immediate  dangers  of  an  abdominal  section  are  three: 

1.  Failure  of  the  vital  forces  to  stand  the  shock  of  the  operation.  This 
shock  is  due  principally  to  (a)  the  loss  of  blood,  (b)  the  handling  of  intra- 
peritoneal structures  and  (c)  the  anesthesia. 

2.  Failure  of  the  vital  organs  (heart,  lungs,  kidneys,  and  gastro-intestinal 
tract)  to  perform  the  extra  work  thrown  on  them  in  the  first  few  days  fol- 
lowing the  operation. 

3.  The  development  of  infection,  causing  general  peritonitis  or  localized 
suppuration. 

PREPARATIONS 

For  Abdominal  Section 

In  order  to  reduce  to  a  minimum  the  dangers  of  the  operation,  careful 
preparation  is  required. 

The  operation  should,  when  possible,  be  carried  out  in  the  clean,  well- 
arranged  operating  room  of  a  hospital,  even  though  the  patient  has  to  be 
moved  a  considerable  distance  to  obtain  the  requisite  hospital  facilities.  Ab- 
dominal section  is  too  serious  an  operation  to  be  undertaken  in  the  home 
if  the  patient's  condition  will  permit  her  removal  to  a  hospital. 

When  the  operation  must  be  performed  at  the  home  of  the  patient,  the 
room  should  be  made  as  clean  and  free  from  dust  as  possible  by  the  follow- 
ing steps: 


1068  INVASION    OF    THE    PEKITOXEAL    CAVITY 

a.  One  or  two  days  before  operation  remove  the  bric-a-brac  and  super- 
fluous furniture  and  sweep  tlie  walls,  ceiling  and  floor  thorouglily. 

b.  The  carpet  may  be  removed,  leaving  the  bare  floor,  or,  after  sweeping 
the  carpet  well,  it  may  be  covered  completely  with  oilcloth  well  tacked  down. 

c.  All  the  woodwork  should  then  be  thoroughly  scrubbed  with  soap  and 
water  and  afterward  with  an  antiseptic  solution. 

The  further  preparations  for  the  operation  may  be  divided  into  three  parts 
as  follows: 

A.  Preparation  of  the  patient. 

B.  Preparation  of  instruments  and  dressings. 

C.  Preparation  of  operator  and  assistants. 

A.  Preparation  of  the  Patient.  The  patient,  having  been  subjected  to  a 
careful  general  examination,  including  urine  analysis,  to  exclude  contraindica- 
tions, is  sent  to  the  hospital  one  or  two  days  before  operation,  that  the  proper 
preparation  may  be  carried  out.  Of  course  there  are  cases  of  rapidly  spread- 
ing pelvic  inflammation,  or  of  intraabdominal  hemorrhage  or  injury,  in  which 
the  abdomen  must  be  opened  at  the  earliest  possible  moment.  In  such  a  case 
there  is  no  time  for  preliminary  preparation — careful  immediate  sterilization 
is  carried  out  and  the  abdomen  is  then  opened.  But  when  the  case  is  not  an 
emergency  one,  the  preliminary  iDreparation  should  be  made.  It  gives  the 
patient  a  decidedly  better  chance  of  complete  and  uninterrupted  recovery. 

The  purposes  of  this  preliminary  preparation  are  : 

a.  To  tone  up  the  patient's  nervous  system  so  that  she  will  be  better 

able  to  stand  the  operation. 

b.  To  see  that  the  kidneys  are  in  good  working  order,  and  to  prepare 

the  urine  for  possible  catheterization. 

c.  To  nourish  the  patient  so  as  to  limit  intestinal  decomposition,  and 

to  empty  the  intestinal  tract  well  just  before  oj)eration. 

d.  To  prepare  a  sterile  field  for  the  operative  work. 

These  desired  results  are  secured  by  a  iDrogram  ordinarily  about  as  fol- 
lows, supposing  the  time  for  operation  to  be  an  early  morning  hour: 

1.  Nervous  System  and  General  Measures.  For  two  or  three  days  before 
operation,  the  patient  is  gi^^n  strychnia  sulphate  %o  S^-  l^y  mouth  every  four 
to  eight  hours,  depending  upon  the  amount  of  stimulation  needed.  If  the 
patient's  stomach  is  much  disturbed,  this  may  be  given  hypodermatically. 
Such  other  medicines  should  be  given  as  are  indicated  by  pain  or  nausea,  or 
cough  or  other  symptoms.  If  there  is  a  vaginal  discharge,  give  an  antiseptic 
douche  once  or  twice  daily. 

2.  Kidneys  and  Urine.  Determine  whether  the  kidneys  are  doing  their 
Avork  well.  Make  the  regular  analysis  of  the  urine,  and,  when  indicated,  the 
special  examinations.  As  the  patient  may  have  to  be  catheterized  after  opera- 
tion, it  is  well  to  give  some  urinary  antiseptic  for  a  day  or  two  before — such, 


ABDOMINAL    SECTION  1069 

for  example,  as  urotropin,  5  grains  in  glass  of  water  every  eight  hours.    Have 
the  patient  take  water  rather  freely. 

Formerly  the  writer  took  particular  pains  to  thoroughly  saturate  the 
patient  with  water  before  operation,  for  the  purpose  of  aiding  the  kidney 
action  after  operation  and  diminishing  the  thirst,  but  he  has  discontinued  the 
practice  as  a  routine  because  he  found  certain  drawbacks— the  principal  one 
l^eing  that  it  interfered  with  spontaneous  urination  after  operation.  The 
avoidance  of  catheterization  is  much  to  be  desired  and  can  usually  be  accom- 
plished, provided  the  bladder  does  not  fill  until  the  patient  has  well  recovered 
from  the  anesthesia.  In  the  water  saturated  patients,  the  urine  is  secreted  so 
rapidly  that  frequently  the  bladder  becomes  distended  before  the  reflexes  are 
sufficiently  established  to  bring  about  spontaneous  urination.  In.  certain  cases, 
however,  where  the  kidneys  are  defective,  the  author  still  employs  it. 

3.  Diet  and  Laxatives.  Light  diet  is  to  be  given  up  to  and  including  noon 
of  the  day  before  operation,  then  liquids  only,  but  with  water  in  abundance. 
After  midnight,  just  preceding  the  operation,  nothing  is  to  be  given  by  mouth 
but  water — the  water  may  be  continued  up  to  within  an  hour  of  the  operation. 
A  dose  of  castor  oil  (1  to  2  ounces)  is  to  be  given  about  3  p.m.  the  day  before 
operation,  and  the  next  morning  an  enema  until  the  water  returns  clear. 

The  idea  is  to  have  the  intestinal  tract  in  as  nearly  a  normal  condition  as 
possible  (hence  no  abnormal  putrefaction),  with  simply  a  good  clearing  out 
by  a  non-irritating  purgative  just  before  the  operation.  Experience  has 
shoAvn  that  this  simple  method  of  preparation  brings  the  patient  to  the  operat- 
ing table  in  better  condition  and  causes  less  disturbance  after  the  operation 
than  the  prolonged  dieting  and  purging  formerly  employed.  The  latter  upset 
the  functional  routine  of  the  intestine,  disturbed  the  normal  peristalsis,  in- 
creased the  intestinal  irritation  and  putrefaction,  and  reduced  the  patient's 
strength. 

When  there  are  complications  that  may  necessitate  resection  of  the  in- 
testine or  opening  of  the  stomach,  then,  of  course,  the  usual  preoperative 
measures  for  approximate  sterilization  of  the  upper  intestinal  tract  should  be 
employed. 

4.  Sterilization  of  the  Field.  In  the  preparation  of  the  operative  field,  as 
in  the  intestinal  preparation,  the  trend  of  practice  has  been  toward  simplicity. 
It  has  been  found  that  some  of  the  measures  formerly  employed  served  to 
irritate  the  skin  and  increased  rather  than  diminished  the  chance  of  inflam- 
mation. This  was  true  particularly  of  the  strong  antiseptics  applied  for  long 
periods  preceding  operation.  Instead  of  the  extensive  soap  poultice  and  the 
prolonged  antiseptic  pack,  the  following  method,  with  minor  modifications,  is 
now  employed  generally: 

The  afternoon  before  operation  the  abdomen  is  lathered  and  shaved.  It 
is  then  scrubbed  with  green  soap  and,  after  soap  is  removed,  with  sterile 
water,  and  then  the  surface  is  washed  with  alcohol.     The  cleansed  surface  is 


1070  IXVASIOX    OF    THE    PEPJTOXEAL    CAVITY 

covered  ^vitli  a  sterile  to^rel  or  sterile  cotton,  vhicli  is  lield  in  place  with  a 
binder. 

After  the  patient  is  anesthetized,  the  sterile  dressing  is  removed  and  the 
surface  is  painted  Avith  a  31/2  per  cent  solntion  of  iodine  in  alcohol.  To  provide 
the  solution,  the  tincture  of  iodine  may  be  diluted  with  alcohol  to  one-half 
strength  or,  if  preferred,  iodine  crystals  may  be  dissolved  in  95  per  cent 
alcohol.  The  application  should  be  made  from  the  area  of  incision  outward, 
so  that  this  area  may  not  be  contaminated  by  material  brought  from  the  periph- 
ery. After  the  first  coating  of  iodiiie  has  dried  (in  two  or  three  minutes) 
a  second  coating  is  applied.  The  sterile  towels  and  sheets  are  then  arranged  • 
about  the  field  and  the  incision  is  made.  If  preferred,  a  5  per  cent  solution 
of  iodine  may  be  used,  in  which  case  the  surface  is  coated  but  once. 

Some  operators  have  the  line  of  incision  washed  Avith  alcohol,  to  remove 
the  iodine,  while  others  prefer  to  cut  right  through  the  iodine  coating.  It 
makes  little  difference  if  the  custom  of  clamping  the  peritoneum  to  towels 
is  followed.  This  prevents  any  protruding  coils  of  intestines  from  coming  in 
contact  with  the  iodine. 

After  the  operation  all  the  remaining  iodine  should  be  removed  with 
alcohol  before  the  patient  leaves  the  table  and  before  any  adhesive  strips  are 
applied.  Some  patients  have  an  idiosyncrasy  to  iodine  and  any  of  it  left  on 
the  skin  causes  a  severe  dermatitis,  particularly  under  the  adhesive  strips. 

If  spinal  anesthesia  is  to  be  used,  the  lumbar  region  is  prepared  in  the 
same  way. 

B.  Preparation  of  Instruments  and  Dressings.  There  are  several  ways  of 
preparing  instruments,  sutures,  dressings,  etc. 

The  usual  method  is  as  follows : 

1.  Instruments  are  boiled  ten  to  fifteen  minutes.  They  must  be  entirely 
immersed  in  the  water  and  the  water  must  boil  (not  simply  simmer)  for  at 
least  ten  minutes.  A  1  per  cent  solution  of  sodium  carbonate  (washing  soda) 
is  preferable  to  plain  water,  as  it  tends  to  prevent  rusting  of  instrilments. 
There  are  a  few  exceptions  to  the  boiling  rule.  The  knives  and  scissors  are 
usually  soaked  in  95  per  cent  carbolic  acid  for  ten  minutes  or  in  10  per  cent 
carbolic  solution  for  half  an  hour,  as  boiling  tends  to  dull  them.  However,  if 
in  a  hurry,  they  may  be  boiled  with  the  other  instruments,  in  which  case  the 
cutting  edge  should  be  wrapped  in  cotton. 

2.  Gauze  sponges  and  pads  and  dressings  are  sterilized  in  the  steam  steril- 
izer. The  gOAvns  for  operator  and  assistants  and  the  sterile  cloths  and  sheets, 
and  instruments,  trays  and  basins  are  put  through  the  same  process. 

In  emergency  work  in  the  countrj^  where  no  steam  sterilizer  is  available,  an 
ordinary  wash  boiler  may  be  used.  The  various  articles  to  be  sterilized 
(gauze,  sponges,  towels,  sheets,  gowns,  etc.)  are  wrapped  in  small  packages, 
each  package  being  wrapped  in  two  thicknesses  of  cloth,  and  are  then  boiled 
for  thirty  minutes.    In  order  to  dry  the  gOAAiis  somewhat,  they  may  be  removed 


ABDOMINAL   SECTION  1071 

from  the  boiler,  wrung  as  dry  as  possible  Avith  clean  hands,  being  careful  not 
to  disturb  the  double  covering,  and  then  dried  in  an  oven. 

In  regard  to  the  form  of  sponges  used,  the  author  strongly  recommends 
the  gauze-strip  sponges  for  abdominal  work  (page  1079).  The  numerous  de- 
tached sponges  ordinarily  used  are  dangerous  and  have  led  to  many  deplorable 
accidents. 

3.  As  to  suture  and  ligature  materials,  silk  and  silkworm-gut  are  boiled 
along  with  the  instruments.  Reliable  catgut  may  be  purchased,  sterilized  and 
ready  for  use. 

4.  The  rubber  gloves  are  wrapped  in  a  towel  and  boiled  along  with  the 
instruments.  After  boiling  they  are  placed  in  1-5000  bichloride  solution. 
They  are  much  easier  put  on  when  partly  filled  with  solution.  The  weak 
bichloride  solution  is  used,  so  as  to  kill  any  bacteria  that  may  work  to  the 
surface  of  the  skin  of  the  hands  during  the  course  of  the  operation.  When 
the  gloves  are  put  on  in  simply  sterile  water,  the  warm  mixture  of  sterile 
water  and  macerated  epithelium,  which  forms  in  the  glove  during  the  course 
of  a  long  operation,  becomes  a  culture  medium  for  the  bacteria  which  work 
to  the  surface  from  the  deeper  layers  of  the  skin,  and  which  may  be  liberated 
in  the  peritoneal  cavity  by  a  puncture  of  the  glove. 

C.  Preparation  of  Operator  and  Assistants.  Everything  that  is  to  come  in 
contact  with  the  operative  field  must  be  sterilized.  The  hands  and  forearms 
of  the  operator  and  assistants  must  be  disinfected  as  far  as  possible,  and 
should  then  be  covered,  so  that  there  is  no  chance  of  direct  contact  of  the 
operative  field  with  the  skin  of  the  hands  or  arms,  for  the  skin  can  not  be  ab- 
solutely sterilized.  Again,  the  operator  and  assistants  must  be  so  covered  as  to 
effectually  protect  the  field  of  operation  from  contamination  by  the  clothing 
or  by  particles  from  the  hair  or  beard,  or  by  particles  carried  in  the  breath. 

The  accomplishment  of  this  thorough  protection  of  the  operative  wound 
has  been  the  object  of  many  decades  of  study  and  experimentation.  The 
present  effective  technic  for  the  preparation  of  the  operator,  as  well  as  all 
the  other  antiseptic  and  aseptic  preparations,  was  attained  gradually  by 
improvements  added  year  by  year,  but  it  is  all  the  direct  outgrowth  of  the 
epoch-making  work  of  Pasteur  and  of  Lister.  The  following  are  the  steps 
in  the  preparation  of  the  operator  and  assistants : 

1.  The  sleeves  are  rolled  well  up  above  the  elbows  and  the  finger-nails  are 
trimmed  short  and  cleaned  thoroughly. 

2.  The  hands  and  forearms  are  then  scrubbed  carefully  and  vigorously, 
for  from  three  to  five  minutes,  with  Avarm  water  and  some  liquid  preparation 
of  green  soap — using  a  stiff  brush  and  giving  particular  attention  to  the 
irregularities  about  the  nails  and  knuckles  and  to  the  spaces  between  the 
fingers  at  their  junction  with  the  hand.  Where  the  brush  causes  undue  irri- 
tation of  the  skin,  gauze  is  preferable  for  scrubbing  the  arms,  but  not  the 
hands. 


1072  INVASION    OF    THE    PERITONEAL    CAVITY 

3.  Then  the  soap  is  washed  off  with  sterile  water,  and  the  hands  and 
forearms  are  scrubbed  in  80  per  cent  alcohol  with  ganze. 

4.  Then  they  are  scrubbed  in  bichloride  solution  (1-2000),  with  a  brush 
or  gauze. 

5.  The  sterile  gown  is  then  put  on,  the  hair  and  mouth  and  neck  and  greater 
part  of  the  face  are  covered  with  gauze  by  the  nurse,  the  rubber  gloves  and 
sterile  muslin  sleeves  are  adjusted  and  the  operator  is  ready  to  begin.  The 
gauntlet  of  the  rubber  glove  is  brought  up  over  the  lower  end  of  the  sterile 
sleeve  to  hold  it  in  place,  and  the  arm  is  thus  securely  covered  and  there  is 
no  chance  for  any  skin  surface  to  come  in  contact  with  the  wound. 

The  assistants  must  go  through  the  same  process. 

The  process  of  hand  disinfection  given  above  is  kno^vn  as  the  ''alcohol- 
bichloride"  method.  It  is  also  called,  from  its  originator,  the  Fiirbringer 
method.  ',   ■  ' ^1  % 

There  are  three  methods  of  hand  disinfection  which  are  much  used.  The 
thorough  scrubbing  with  green  soap  and  warm  water  is  common  to  all  of  them. 
The  further  steps  differ  as  follows : 

a.  The  "alcohol-bichloride"  method.  The  various  steps  in  this  method 
are  given  in  detail  above. 

b.  The  "permanganate  and  oxalic  acid"  method.  The  hands  and  fore- 
arms are  next  immersed  in  a  hot  saturated  solution  of  potassium  permanganate 
and  kept  there  until  the  skin  takes  on  a  dark  brown  color,  then  they  are 
immersed  in  a  hot  saturated  solution  of  oxalic  acid  until  the  skin  again  has 
its  natural  color.  The  oxalic  acid  is  washed  off:  in  sterile  water  or  sterile 
lime  water,  and  the  hands  and  forearms  are  then  Avashed  in  bichloride  solu- 
tion (1-2000). 

c.  The  "chlorinated  lime  and  sodium  carbonate"  method.  After  the  pre- 
liminary scrubbing  a  tablesponful  of  chlorinated  lime  is  taken  in  the  palm 
of  the  hand,  moistened  with  enough  water  to  make  a  thick  paste,  and  then  a 
piece  of  sodium  carbonate  (washing  soda)  about  the  size  of  the  thumb  is 
crushed  in  the  hand  and  rubbed  thoroughly  into  the  lime  paste.  This  mixture, 
containing  nascent  chlorine,  is  then  rubbed  vigorously  into  the  skin  of  the 
hands  and  forearms  for  three  to  five  minutes.  The  parts  are  then  washed  in 
sterile  water,  and  later  in  weak  ammonia  water  to  remove  the  chlorine  odor. 

As  to  the  choice  of  method  of  hand-disinfection,  that  is  largely  a  matter  of 
personal  preference.  Any  one  of  the  above  three  methods,  properly  carried 
out,  will  give  good  practical  hand-disinfection — i.  e.,  from  hands  and  arms 
so  prepared,  infection  will  rarely  if  ever  take  place.  The  important  thing 
is  not  which  method  is  chosen,  but  how  thoroughly  the  chosen  method  is  car- 
ried out.  The  author  has  used  all  three  methods,  and  very  decidedly  prefers 
the  "alcohol-bichloride"  method,  though  nothing  can  be  said  against  the 
others. 


ABDOMINAL    SECTION  1073 

Absolute  disinfection  of  the  hands  and  arms  is  impossible  by  any  method, 
as  the  disinfection  is  necessarily  confined  to  the  superficial  layers  of  the  epider- 
mis. Bacteria  situated  in  the  deeper  layers  of  the  epidermis  may  work  to 
the  surface  during  the  course  of  the  operation;  hence  the  importance  of 
thoroughly  covering  the  prepared  hands  and  arms  with  rubber  gloves  and 
sterile  sleeves. 

REGULAR  STEPS 

Tn  Abdominal  Section 

In  order  to  present  some  idea  of  the  main  features  of  this  important  thera- 
peutic measure,  the  regular  steps  in  this  operation  will  be  simply  enumerated, 
and  later  some  of  the  special  points  that  require  attention  considered  briefly. 

The  regular  steps  incident  to  every  case  of  abdominal  section  are  as 
follows : 

1.  Anesthesia. 

2.  Incision. 

3.  Exploration. 

4.  Correction  of  pathologic  condition. 

5.  Toilet  of  peritoneum. 

6.  Closure  of  incision. 

7.  Dressing. 

1.  Anesthesia.  Ether  is  safer  than  chloroform,  and  is  to  be  preferred  in 
all  cases  except  where  there  is  some  definite  contraindication. 

There  is  neither  space  nor  occasion  here  for  a  general  consideration  of 
anesthesia.  There  is  one  point,  however,  that  is  important,  and  that  is  the 
position  of  the  patient's  arms  during  anesthesia.  Many  cases  of  paralysis  of 
one  or  both  arms  following  anesthesia  have  been  reported — the  paralysis  last- 
ing for  many  months  and  sometimes  for  a  year.  It  is  due  largely  to  faulty 
position  of  the  arms  during  anesthesia.  This  is  a  serious  matter  and  attention 
should  be  called  to  it  in  every  work  dealing  with  anesthesia — and  yet  it  is 
seldom  mentioned.  In  1905  the  author  reported  two  eases  of  such  brachial 
paralysis  in  detail  to  the  St.  Louis  Medical  Society,  called  attention  to  previous 
work  and  investigations  on  the  subject,  and  demonstrated,  directly  on  the  cada- 
ver, the  compression  of  the  brachial  plexus  by  the  clavicle  when  the  arm  is  above 
the  head.*  As  stated  in  the  article,  this  has  long  been  recognized  as  the  cause 
of  the  paralysis,  the  attention  of  the  profession  generally  having  been  first 
called  to  the  subject  by  Budinger  in  1894.  No  case  of  paralysis  has  ever 
occurred,  as  far  as  known,  when  the  elbows  were  kept  to  the  side  as  here 
indicated. 


*Brachial   Paralysis   Following   Surgical   Anesthesia ;    Report   of   Two    Cases,    H.    S.    Crossen,    M.D., 
Journal   of  Missouri   State   Medical  Association,  vol.   I,   No.    10,    1905. 


1074 


INVASION    OF    THE   PERITONEAL    CAVITY 


2.  Incision.  In  abdominal  section  for  pelvic  disease  the  incision  is  made 
almost  invariably,  in  the  median  line.  All  parts  of  the  pelvis  may  be  reached 
from  snch  an  incision  and,  in  practically  every  case,  exploration  of  the  whole 
pelvis  should  be  made.  Ordinarily  the  incision  is  begun  about  midway  from 
the  umbilicus  to  the  symphysis  and  continued  downward  three  or  four  inches. 
If  th^re  is  no  large  solid  tumor,  the  incision  is  made  small  at  first,  but  large 
enough  to  admit  the  fingers  or  hand  into  the  pelvis  for  exploration.    As  a  rule 


Fig.   790.     The  Abdominal    Dressing.      The    Binder    applied. 


the  primary  incision  is  about  four  inches  long.     If  the  abdominal  walls  are 
very  thin,  it  may  be  shorter ;  if  they  are  very  thick,  it  must  be  longer. 

The  lower  the  incision  is  placed,  the  more  easily  the  deeper  portions  of  the 
pelvic  cavity  may  be  reached,  but  the  incision  must  not  be  low  enough  to 
injure  the  bladder.  When  a  tumor  is  present,  the  bladder  may  be  dra^^ai  up 
considerably;  consequently  in  such  a  case  the  incision  must  not  be  extended 
low  until  the  peritoneal  cavity  has  been  opened  and  the  bladder  located.  If 
it  is  thought  that  the  bladder  may  be  drawn  so  high  as  to  interfere  with  the 


ABDOMINAL   SECTION  1075 

ordinary  incision,  a  steel  bougie  may  be  introduced  into  the  bladder  and  the 
height  of  its  cavity  determined  before  the  incision  is  made. 

In  cutting  through  the  abdominal  wall  it  is  not  necessary  to  strike  the 
tendinous  tissue  between  the  recti  muscles.  If  the  incision  is  made  a  little 
to  one  side  of  the  tendinous  center  and  passes  through  the  rectus  muscle  of 
that  side,  it  makes  little  difference.  Consequently,  no  time  should  be  lost  try- 
ing to  make  a  careful  dissection  exactly  in  the  median  line. 

The  incision  is  continued  through  the  skin  and  the  subcutaneous  fat  and 
fascia,  and  the  rectus  muscle  with  its  tendinous  sheath,  down  to  the  loose 
subperitoneal  fat.  When  the  subperitoneal  tissue  is  reached,  all  bleeding  is 
stopped,  and  the  subperitoneal  fat  and  connective  tissue  are  cut  through  be- 
tween two  dissecting  forceps.  The  peritoneum  is  then  picked  up  with  the 
dissecting  forceps  and  a  short  cut  is  made  in  it,  and  this  opening  in  the  peri- 
toneal cavity  is  enlarged  by  scissors  or  knife. 

Sterile  towels  now  may  be  fastened  on  either  side  to  the  edges  of  the  perineum 
to  avoid  any  contact  with  exposed  skin  surface. 

3.  Exploration.  When  the  proper  opening  has  been  made,  the  hand  is  in- 
troduced into  the  peritoneal  cavity  and  the  various  pelvic  organs  are  out- 
lined and  the  pathologic  condition  determined  as  accurately  as  possible. 

4.  Correction  of  Pathologic  Condition.  After  the  exploration  of  the  pelvic 
cavity  and  the  determination  of  the  exact  condition  present,  the  particular 
measures  to  be  employed  will  depend  on  the  nature  of  the  trouble — the  various 
affections  requiring  very  different  methods  of  treatment. 

5.  Toilet  of  the  Peritoneum.  All  blood  and  clots  are  sponged  out  of  the 
pelvis  and,  as  far  as  practicable,  the  pedicle  ends  are  turned  under  and  all  raw 
surfaces  covered  with  ijeritoneum.  All  abdominal  pads  are  then  removed,  the 
intestines  are  permitted  to  come  back  into  the  pelvis  (the  patient  having  been 
lowered  from  the  Trendelenburg  posture)  and  the  omentum  is  spread  out 
in  its  proper  place. 

6.  Closure  of  Incision.  There  are  two  methods  of  closing  the  incision — 
(a)  by  ''through  and  through  sutures"  of  silkworm-gut  and  (b)  by  "tier 
sutures ' '  of  catgut  or  other  absorbable  material.  Except  in  hurry  cases,  where 
it  is  exceptionally  important  to  get  the  abdomen  closed  as  quickly  as  possible, 
the  preferable  method  is  the  latter — approximation  by  the  tier  sutures  of  cat- 
gut, with  or  without  two  or  three  tension  sutures  of  silkworm-gut. 

7.  Dressing.  The  dressing  of  the  abdominal  wound  consists  of  a  large 
thick  dressing  of  sterile  gauze  over  the  wound,  next  to  that  a  layer  of  sterile 
absorbent  cotton  covering  the  anterior  surface  of  the  abdomen,  and  over  that 
a  medium-thick  layer  of  sterile  common  cotton  to  turn  any  water  that  might 
be  spilled  on  the  dressing  during  convalescence  and  to  give  even  elastic  pres- 
sure at  all  points— the  whole  held  in  place  by  a  binder  about  the  abdomen, 
with  perineal  straps  to  hold  it  well  down  (Fig.  790). 


1076  INVASION    OF    THE   PERITONEAL    CAVITY 

SPECIAL  POINTS 

In  Abdominal  Section 

There  are  a  number  of  special  items  that  must  receive  careful  consideration 
by  every  one  doing  abdominal  section  work.  Among  these  may  be  mentioned  the 
following:  ' 

1.  Drainage. 

2.  Shock. 

3.  Injury  to  adjacent  organs. 

4.  Foreign  bodies  in  abdomen. 

1.  Drainage.  The  rule  in  abdominal  surgery  is  never  to  drain  unless  there 
is  some  special  reason  for  it,  and  that  special  reason  must  be  a  very  strong 
one.  Experience  has  abundantly  shown  that  in  all  but  exceptional  cases 
the  best  results  are  obtained  by  closing  the  peritoneal  cavity  completely  and 
leaving  Nature  to  carry  on  the  reparative  process  alone,  undisturbed  by  tubes 
or  gauze  or  other  form  of  drainage. 

That  small  percentage  of  cases  in  which  drainage  is  advisable  includes  the 
following  classes : 

a.  Rapidly  spreading  inflammation  of  the  peritoneum  or  acute  general 
peritonitis.  In  such  cases  free  drainage  is  indicated,  and  as  a  rule  the  freer 
the  better. 

b.  Rupture  of  abscess  in  pelvis.  This  accident  happens  not  infrequently 
during  the  enucleation  of  an  inflammatory  mass  containing  pus.  In  some 
cases  the  pus  is  not  confined  in  any  removable  sac,  but  has  burrowed  in  various 
directions  among  the  adherent  organs.  In  such  a  case  as  soon  as  the  adhesions 
are  separated  the  pus  flows  out  into  the  peritoneal  cavity. 

c.  Persistent  free  oozing  from  surfaces  left  after  the  enucleation  of  an  in- 
flammatory mass.  Here  the  effect  desired  is  pressure  rather  than  drainage, 
but,  as  the  end  of  the  gauze  used  for  pressure  must  be  brought  out  through 
the  abdominal  w^ound  or  through  the  vagina,  it  is  usually  referred  to  as  a 
drain  or  pack. 

2.  Shock.  The  principal  factors  in  shock  are  (a)  loss  of  blood,  (b)  ex- 
posure and  handling  of  abdominal  contents  and  (c)  long  anesthesia.  To 
avoid  shock,  therefore,  particular  attention  must  be  given  to  the  folloAving 
points : 

a.  Careful  hemostasis.  All  vessels  that  can  be  located  are  ligated  or 
clamped  before  they  are  divided.  In  cutting  through  ligated  tissues,  forceps 
are  in  readiness  to  catch  any  vessel  that  may  have  escaped  the  ligature  or  upon 
which  the  ligature  is  not  tight  enough. 

b.  Protection  of  the  abdominal  contents,  so  far  as  possible,  from  handling 
and  exposure.  The  Trendelenburg  posture  accomplishes  this  to  a  large  ex- 
tent.   In  this  posture  the  intestines  and  omentum  gravitate  into  the  upper  part 


ABDOMINAL    SECTION  1077 

of  the  abdominal  cavity,  away  from  the  field  of  operation.  Those  parts  that 
still  tend  to  protrude  into  the  pelvis  are  held  out  of  the  way  by  gauze,  which, 
at  the  same  time,  serves  to  wall  off  the  pelvis  from  the  abdominal  cavity. 
"When  the  intestines  are  unavoidably  permitted  outside  of  the  peritoneal 
cavity,  they  should  be  kept  covered  Avith  large  sterile  towels  soaked  in  hot 
saline  solution. 

c.  Minimum  duration  of  anesthesia.  To  cut  down  the  duration  of  the 
operation  and  consequently  of  the  anesthesia,  the  operator  should  work 
rapidly — as  rapidly  as  is  consistent  with  safety  and  accuracy — but  accuracy 
must  not  be  sacrificed  to  haste. 

3.  Injury  to  Adjacent  Organs.  The  ureter,  the  bladder  and  the  intestines 
are  the  organs  particularly  liable  to  injury  in  difficult  cases.  Ordinarily  an 
injury  of  any  of  these  organs  occurring  in  the  course  of  an  operation  must 
be  repaired  at  once  or  at  the  close  of  the  operation,  and  any  one  doing  pelvic 
surgery  must  be  prepared  to  immediately  take  care  of  the  injuries  mentioned. 

4.  Foreign  Bodies  Left  in  the  Abdomen.  The  absolute  certainty  of  the 
removal  of  all  articles  carried  into  the  peritoneal  cavity  is  a  subject  that 
deserves  most  careful  consideration.  It  is  surprising  how  easily  and  quickly 
the  intestinal  coils  wdll  enfold  an  object  and  carry  it  out  of  sight  and  touch. 

Sponges.  A  sponge  left  in  the  peritoneal  cavity  following  an  operation 
constitutes  one  of  the  most  deplorable  accidents  of  abdominal  surgery.  This 
is  not  a  new  subject.  Much  has  been  written  upon  it  and  many  cases  have 
been  reported,  and  many  suggestions  have  been  made  as  to  preyentive  meas- 
ures. But  all  such  measures  hitherto  proposed  have  broken  down  under  the 
various  circumstances  and  vicissitudes  of  surgical  work,  as  evidenced  by  the 
records  subsequently  cited.  In  connection  with  this  subject  attention  will  be 
called  to  the  foUoi^ang  facts: 

1.  Sponges  are  lost  in  the  peritoneal  cavity  much  more  frequently  than  is 
generally  supposed.  And  it  must  be  kept  in  mind  that  the  reported  cases 
represent  only  a  small  proportion  of  the  recognized  cases,  for,  naturally,  the 
accident  is  not  given,  publicity  except  where  there  is  some  special  reason  for 
doing  so.  In  any  large  body  of  surgeons  a  little  experience  meeting,  in  which, 
testimonies  are  freely  given,  will  bring  to  light  a  number  of  unreported  cases 
of  this  accident. 

Furthermore,  many  cases  are  not  even  recognized.  The  patient  dies  with 
evidence  of  peritonitis ;  there  is  no  suspicion  of  any  foreign  body  having  been 
left  in  the  abdomen,  no  postmortem  examination  is  made  and  the  death  is 
supposed  to  be  clue  to  ordinary  peritonitis.  The  possibilities  in  this  direction 
are  indicated  by  the  fact  that  in  a  reported  series,  in  thirty-nine  of  the  cases 
the  accident  was  recognized  only  on  postmortem  examination,  when  the 
sponge  was  found,  but  would  have  remained  unknown  had  there  been  no 
autopsy. 

2.  It  is  a  most  serious  accident.    In  this  large  series  of  cases  collected  more 


1078  INVASION    OF    THE   PERITONEAL    CAVITY 

than   one-fourth   of  the   patients   died,    and   of   those   who   recovered   many 
went  through  weeks  and  months  of  suifering. 

3.  To  persons  outside  the  profession  the  accident  seems  absolutely  inex- 
cusable. They  can  understand  how  other  complications  may  arise,  such  as 
hemorrhage  or  sepsis  or  kidney  failure,  in  spite  of  every  precaution,  but  they 
can  imagine  no  reasonable  excuse  for  allowing  a  sponge  to  be  lost  in.  the 
patient's  interior.  To  those  not  familiar  with  surgical  work  it  seems  past 
belief  that  the  surgeon  would  carry  into  the  peritoneal  cavity  anything,  the 
removal  of  which  was  not  provided  for  with  absolute  certainty. 

The  growing  cognizance  of  the  public  in  regard  to  the  occurrence  of  this 
accident  and  the  feeling  in  regard  to  the  responsibility  for  it  are  reflected  in 
the  increasing  number  of  lawsuits  connected  therewith  (see  Chapter  xviii). 

4.  There  has  hitherto  been  no  sure  preventive  method  which  Avas  appli- 
cable in  all  the  circumstances  of  abdominal  surgery.  The  list  of  preventive 
measures  recorded  later  shows  that  much  thought  has  been  given  to  devising 
means  for  preventing  this  accident.  Rules  interminable  have  been  proposed, 
and  expensive  and  cumbersome  racks  and  stands  devised  for  the  purpose. 
Not  one  of  these  devices,  however,  has  proved  absolutely  safe,  for  the  reason 
that  in  their  use  the  certain  removal  of  all  sponges  carried  into  the  abdomen 
depends  on  the  studied  attention  of  the  operator  or  on  a  system  of  attentive 
cooperation  among  assistants  or  nurses.  While  such  attentive  cooperation 
is  entirely  feasible  under  ideal  conditions  and  with  ideal  persons,  the  fact 
remains  that  it  is  not  secured  and  is  not  likely  to  be  secured  under  the  variable 
circumstances  of  abdominal  work.  The  many  emergencies  which  arise  in 
the  course  of  abdominal  operations,  the  changing  assistants  and  nurses,  the 
hurried  operations  at  night  in  the  hospital  with  short  help,  the  operations  in 
private  homes  where  the  patient  can  not  be  got  to  the  hospital  at  all — all 
these  conditions  play  havoc  with  safety  arrangements  depending  upon  a  nicely 
balanced  system  of  rules  and  cooperation  or  on  the  use  of  cumbersome  racks 
or  stands. 

There  is  not  space  here  to  take  up  in  detail  the  various  ways  in  which  mis- 
takes have  occurred;  suffice  it  to  say  that  a  review  of  the  cases  where  de- 
pendence was  placed  on  counting  shows  an  appalling  list  in  which  a  sponge 
was  left,  because  one  was  hastily  torn  in  two  and  one-half  forgotten,  or  an 
extra  one  was  primarily  included  in  the  bundle  and  missed  in  the  counting, 
or  an  extra  one  was  secured  for  an  emergency  during  the  operation,  or  some 
loose  piece  of  gauze,  not  intended  for  intraperitoneal  use,  slipped  in  while  near 
the  wound,  or  a  mistake  was  made  in  the  final  count  of  the  sponges  removed. 
It  is  astonishing  what  slight  inattention  may  lead  to  a  sponge  being  left, 
and  the  consequent  death  of  the  patient. 

The  method  of  attaching  a  tape  to  each  sponge  and  then  fastening  a  for- 
ceps to  the  tape  and  at  the  same  time  to  the  abdominal  sheet,  is  the  method 
probably  in  most  general  use.  It  has  a  record  of  many  accidents — the  tape 
pulled  off  the  sponge,  or  there  was  a  failure  to  attach  the  forceps,  or  the  for- 


ABDOMINAL    SECTION  1079 

ceps  failed  to  hold  well.  In  one  case  recorded  the  sponge,  tape  and  forceps 
were  all  lost  in  the  cavity. 

The  difficulty  of  guarding  absolutely  against  leaving  a  sponge  in  the  abdo- 
men is  such  that  entire  security  against  this  fatal  accident  is  counted  on©  of 
the  unsolved  problems  of  abdominal  work.  Practically  all  writers  on  the 
subject  state  that  there  is  no  guaranty  against  its  occurrence,  even  in  routine 
hospital  work  and  Avith  all  the  rules  of  cooperation  and  the  special  apparatus 
designed  to  prevent  it.  Neugebauer,  in  a  most  exhaustive  consideration  of  the 
subject,  comes  to  the  conclusion  that  the  accident  is,  to  a  certain  extent,  un- 
avoidable. Schachner,  in  an  excellent  paper,  states,  ''So  long  as  surgery 
continues  an  art,  just  so  long  will  foreign  bodies  continue  to  be  unintentionally 
left  in  the  abdominal  cavity."  In  an  article  published  recently,  Findley 
states,  "In  former  years  the  abdominal  surgeon  was  seriously  disturbed  by 
well-grounded  fears  of  secondary  hemorrhage  and  sepsis,  but  surgery  has 
mastered  these  problems  to  a  large  degree  and  they  are  little  feared  and 
seldom  experienced.  Now  it  is  the  thoughts  of  the  sponge  that  disturb  the 
night's  repose  when  the  report  comes  that  something  has  gone  wrong  with 
our  patient.  The  operator  never  can  rid  himself  of  the  feeling  of  uncertainty 
as  to  the  possibility  of  leaving  a  sponge."  This  expresses  very  well  the 
feeling  of  those  who  have  given  attention  to  this  subject,  and  particularly  of 
those  who  have  personally  experienced  the  accident  and  have  thus  been 
brought  face  to  face  with  a  concrete  exemplification  of  the  inadequacy  of  the 
usual  methods. 

The  continued  occurrence  of  this  fatal  accident  and  the  failure  of  the 
preventive  methods  in  general  use  constitute  sufficient  reason  for  calling 
attention  to  a  method  which  the  author  has  used  with  much  satisfaction  for 
the  past  four  years.  This  method  gives  entire  security  and  at  the  same 
time  is  simple  and  inexpensive,  and  is  effective  in  all  conditions  of  abdominal 
work — in  the  emergency  operation  in  the  country  with  unfamiliar  assistants, 
as  well  as  in  the  routine  hospital  work.  The  failure  of  the  safety  methods  in 
general  use  is  due  to  their  dependence  upon  sustained  attention  concerning 
the  sponges,  which  attention  on  the  part  of  the  surgeon  can  not  be  given  to 
the  sponges  for  it  is  required  elsewhere.  A  method,  to  be  effective  under  all 
circumstances,  must  be  practically  automatic,  insuring  the  removal  of  all 
gauze  without  particular  attention  on  the  part  of  any  one  at  the  time  of  the 
operation. 

The  Method 

The  underlying  principle  of  this  method  is  the  elimination  of  all  detached 
pads  and  sponges.  In  place  of  them  long  strips  of  gauze  are  used,  each  strip 
packed  into  a  small  bag  in  such  a  way  that  it  may  be  dra^^ai  out  a  little  at  a 
time  as  needed. 

The  author  was  led  to  a  study  of  the  subject  and  the  adoption  of  this 
method  by  an  unfortunate  experience.    Following  th^  usual  technic  he  oper- 


1080  INVASION    OF    THE   PERITONEAL    CAVITY 

ated  for  years  without  accident,  but  five  years  ago  lie  left  a  gauze  pad  in  the 
abdomen.  The  case  was  one  of  diffuse  pelvic  suppuration,  requiring  extensive 
drainage,  and,  fortunately,  the  pad  was  discovered  and  extracted  through  the 
drainage  opening  about  two  weeks  later.  The  patient  recovered  without 
serious  result  from  the  accident — but  the  lesson  was  not  lost.  He  determined 
to  find  some  method  that  would  really  prevent  such  an  accident — a  method 
which  would  be  entirely  under  the  control  of  the  operator  and  first  assistant 
(a  greater  division  of  responsibility  increases  the  danger)  and  one  which 
would  occasion  no  delay  in  the  closing  steps  of  the  operation.  There  had  to  be 
taken  into  consideration  the  large  pads  for  holding  the  intestines  out  of  the 
way  and  the  small  pads  and  gauze  pieces  for  sponging.  In  place  of  several 
large  pads  for  packing  back  the  intestines,  the  large  roll  of  gauze  was  adopted, 
then  in  use  by  a  number  of  operators,  and  found  satisfactory. 

The  matter  of  the  small  pads  and  sponges,  however,  was  not  so  easily 
disposed  of.  It  was  imperative  to  find  some  method  that  would  do  away 
entirely  with  dependence  on  the  counting  of  the  sponges  at  the  close  of  the 
operation. 

After  a  good  deal  of  experimenting  with  various  methods,  it  became  evident 
that  if  safety  were  to  be  secured,  the  detached  pads  and  sponges  must  be 
eliminated  entirely.  In  pursuance  of  that  idea  the  author  devised  the  method 
here  described.  The  principle  of  this  method  is  that  no  detached  piece  of  gauze 
shall  enter  the  abdominal  cavity.  Each  piece  of  gauze  introduced  for  sponging 
is  simply  part  of  a  very  long  piece,  the  greater  part  of  which  is  always  outside 
the  cavity.  To  make  assurance  doubly  sure,  he  has  recently  put  the  large  roll  of 
gauze  above  mentioned  into  a  bag,  similar  to  the  bags  for  the  narrow  strips, 
except  that  it  is  open  on  the  side.  As  now  used,  therefore,  the  set  consists  of 
the  following: 

Gauze-Strip  Sponges  for  A'bdominal  Section.* 

Four  narrow  strips — 10  yd.  long,  3  in.  wide — 6  thicknesses. 

One  wide  strip — 5  yd.  long,  9  in.  wide — 4  thicknesses. 

Have  another  set  of  strips   (4  narrow  and  1  wide)   in  reserve. 

For  the  narrow  strips  the  yard-w4dth  of  gauze  is  divided  into  two  strips,  and  each 
of  these,  when  folded  to  six  thicknesses,  is  about  three  inches  wide.  For  the  wide  strip  the 
full  yard-width  of  gauze  is  used — when  folded  to  four  thicknesses  it  is  nine  inches  wide. 
Turn  in  all  raw  edges  so  that  no  raveling  can  be  left  in  the  abdominal  cavity. 

Pack  each  narrow  strip  into  a  separate  small  cloth  bag,  5  in.  wide  and  10  in.  deep, 
and  attach  a  large  safety  pin  to  the  bottom  of  the  bag.  Tlie  safety  pin  is  to  pin  the  bot- 
tom of  the  bag  to  the  abdominal  sheet  at  operation.  Make  the  bag  of  extra  heavy  muslin 
or  drilling,  and  sew  with  French  seams  to  avoid  raveling  on  the  inside.  The  end  of  the 
strip  first  introduced  to  bottom  of  the  bag  should  be  fastened  there  securely  by  stitching 
through  and  through.  Then  pack  the  strip  firmly  into  the  bag  in  such  a  way  that  it  will 
come  out  easily,  a  little  at  a  time  as  needed.     Four  of  these  filled  bags  belong  in  each  set. 

For  holding  the  wide  strip  use  a  bag  6  in.  by   10  in.,   and  open  on  the   side  instead 


*A    detailed   and    illustrated    description    of    this    method    is    found    XV.    Crossen's    Operative    Gyne- 
cology,  p.   573. 


ABDOMINAL   SECTION  1081 

of  at  the  end.  Fold  the  strip  back  and  forth,  thus  forming  a  narrow  pile  about  three  inches 
wide.  Fasten  one  end  of  the  strip  securely  to  the  bottom  of  the  bag  by  sewing  through  and 
through.  Then  place  the  folded  strip  in  the  bag  in  such  a  way  that,  when  pulled  upon,  it 
will  come  out,  a  little  at  a  time,  as  a  wide  strip  suitable  for  packing  back  the  intestines. 
Fold  over  the  open  side  of  bag  and  pin  with  two  large  safety  pins.  The  safety  pins  are 
for  fastening  two  corners  of  the  bag  to  the  abdominal  sheet. 

One  wide  strip  and  four  narrow  strips  constitute  one  set  and  are  to  be  wrapped  to- 
gether in  a  cloth  for  sterilization  in  the  usual  way.  Have  also  an  extra  sterilized  set  in 
reserve.  At  the  operation  the  bag  containing  the  wide  strip  is  to  be  placed  in  hot  normal 
saline  solution.     The  narrow  strips  are  to  be  used  dry. 

This  method  elimmates  all  chance  of  leavmg  a  piece  of  gauze  in  the  abdo- 
men, for  a  large  part  of  the  strip  is  always  outside  the  cavity,  and  the  end  is 
fastened  securely  outside.  An  important  point  is  that  the  sure  removal  of  all 
gauze  is  practically  automatic.  It  does  not  depend  on  the  accuracy  of  a  hur- 
ried counting  of  sponges  at  the  close  of  the  operation  nor  on  catching  each 
sponge-tape  with  a  forceps  as  it  is  put  into  the  cavity,  nor  on  a  studied  "watch- 
ing what  sponges  go  in  and  what  sponges  come  out  of  the  cavity."  Those 
methods  that  depend  for  safety  on  the  observance  of  complicated  rules  or  on 
the  strict  following  of  a  regular  routine,  or  on  the  constant  attention  of  the 
operator,  have  all  broken  down  under  the  difficulties  and  vicissitudes  of  ab- 
dominal surgery,  as  the  reported  cases  clearly  show.  A  method,  to  be  safe 
and  suitable  for  general  use,  must  be  practically  automatic  in  the  removal  of 
all  gauze  carried  into  the  cavity,  must  be  comparatively  inexpensive  in  mate- 
rials and  preparations,  must  be  fairly  simple  and  convenient  in  use,  and  must 
be  applicable  in  every  environment,  including  emergency  work  in  the  country. 
These  requirements  are  met  by  the  method  here  described. 

The  dangers  from  hemorrhage,  and  sepsis  in  clean  cases  have  been  largely 
done  away  with  through  improvements  in  technic,  and  now  this  other  serious 
menace  in  abdominal  work  should  be  eliminated.  The  patient  has  a  right  to 
demand,  and  is  demanding  as  the  many  lawsuits  show  (see  Chapter  xviii), 
that  real  protection  be  afforded  against  leaving  a  sponge  in  the  abdomen.  It 
seems  only  justice  to  those  who  intrust  themselves  to  our  care  that  we  should 
provide  absolute  security  against  this  fatal  accident,  so  far  as  such  security 
is  practically  attainable. 

It  simplifies  the  preparations  for  abdominal  section — all  the  many  pads 
and  sponges  of  various  sizes  being  replaced  by  five  strips  of  gauze.  The  gauze  is 
simply  folded  and  then  tacked  by  a  few  stitches  at  each  end  to  prevent  unfolding. 
Nurses  as  a  rule  welcome  the  method,  stating  that  it  is  much  less  trouble- 
some than  the  sewing  of  the  numerous  small  pads  and  sponges.  The  bags  may 
be  used  again  and  again  after  sterilization. 

Forceps.  In  about  one-fourth  of  the  recorded  cases  of  a  foreign  body  left 
in  the  abdomen,  the  article  left  was  a  forceps  or  piece  of  an  instrument,  or 
other  small  object  used  about  the  wound.  This  calls  attention  forcibly  to  the 
fact  that  small  instruments  should  not  be  allowed  about  an  open  abdominal 
wound.    Neugebauer  long  ago  called  attention  to  this  danger  of  small  instru- 


1082  INVASION    OF    THE   PERITONEAL    CAVITY 

ments,  and  urged  the  use  of  long  instruments  exclusively  in  abdominal  work. 
Many  surgeons  have  adopted  this  safety  measure,  but  there  are  many 
others  who  seem  to  give  no  thought  to  the  matter,  and  continue  to  use  numer- 
ous small  instruments  in  this  dangerous  locality.  It  may  not  be  possible  at 
present  to  entirely  prevent  the  accident  of  leaving  some  article  of  the  surgical 
armamentarium  in  the  abdomen,  but  it  is  possible  to  reduce  the  danger  to  a 
minimum  by  the  use  of  long  instruments  exclusively,  Jind  it  seems  to  me  that 
all  those  who  are  engaged  in  abdominal  surgery  should  be  led  by  common 
prudence  to  adopt  this  simple  expedient.  The  details,  as  carried  out  in  my 
own  work,  are  as  follows :  Every  instrument  used  about  the  wound  is  long — 
so  long  that  a  portion  of  it  is  practically  always  outside  the  abdominal  cavity. 
Again,  if  by  accident  such  an  instrument  should  slip  entirely  into  the  cavity, 
its  length  is  such  that  it  would  almost  certainly  be  felt  when  the  hand  is 
carried  into  the  cavity  for  the  final  palpation  before  closing.  All  the  artery 
forceps,  dissecting  forceps,  tenaculum  forceps,  pedicle  needles,  scissors  and 
other  instruments  for  internal  work  are  from  six  and  one-half  to  eight  inches 
long,  the  shortest  being  the  large  dissecting  scissors  (six  and  one-half  inches). 
The  shortest  instrument  used  anywhere  about  the  wound  is  the  scalpel  (six 
inches),  which  is  laid  aside  as  soon  as  the  peritoneal  cavity  is  open.  The 
needles  and  Murphy  buttons  are  not  brought  near  the  wound,  except  when 
held  with  a  forceps  or  with  a  suture  attached.  No  Michel  clamps  (for  hold- 
ing rubber  tissue  or  gauze  along  the  wound  margin)  or  other  small  unattached 
objects  are  allowed  near  the  wound  as  long  as  the  peritoneal  cavity  is  open. 

VAGINAL  SECTION 

Vaginal  section  is  incision  through  the  vaginal  wall  into  the  peritoneal 
cavity.  If  the  entrance  is  made  behind  the  cervix,  it  is  known  as  ''posterior" 
vaginal  section.  If  the  opening  is  made  in  front  of  the  cervix,  it  is  known 
as  "anterior"  vaginal  section. 

In  some  cases  of  pelvic  disease  it  is  better  to  enter  the  peritoneal  cavity 
from  below;  i.  e.,  by  vaginal  section;  while  in  other  cases  it  is  better  to  enter 
from  above ;  i.  e.,  by  abdominal  section. 

ADVANTAGES 

Of  Vaginal  Section 

The  advantages  of  Vaginal  Section,  in  suitable  cases,  are  as  follows : 

1.  Less  danger.  There  is  less  exposure  and  handling  of  the  intestines  and 
peritoneum.  In  vaginal  section  the  manipulations  are  nearly  all  in  the  pelvic 
cavity,  while  in  abdominal  section  the  central  portion  of  the  great  peritoneal 
sac  is  invaded ;  therefore,  in  vaginal  section  there  is  less  shock  and  less  danger 
of  general  peritonitis.    Again,  if  infection  should  develop  after  vaginal  section, 


VAGINAL    SECTION  1083 

it  is  very  likely  to  be  'Availed  off"  from  the  general  peritoneal  cavity  and  to 
cause  simply  local  suppuration,  whereas  when  infection  appears  after  abdom- 
inal section  it  is  very  likely  to  take  the  form  of  an  acute  general  peritonitis. 

2.  Evacuation  of  pus  without  contamination  of  peritoneal  surfaces.  This 
is  one  of  the  strongest  points  in  favor  of  vaginal  section  in  suitable  cases. 
As  a  rule,  when  there  is  a  large  collection  of  pus  that  can  be  reached  from 
below,  it  should  be  evacuated  that  way.  This  is  particularly  important  if  the 
pus  be  of  recent  origin.  In  such  a  case  it  is  very  important  to  prevent  soiling 
of  the  peritoneal  surfaces  with  this  infectious  fluid.  This  is  accomplished  by 
opening  from  below. 

Again,  in  many  cases  of  pelvic  suppuration  the  pelvic  cavity,  containing 
the  abscess,  is  entirely  shut  off  from  the  general  peritoneal  cavity  by  a  wall 
or  roof  of  inflammatory  exudate,  which  binds  together  the  upper  pelvic 
structures.  "When  operating  from  below  we  work  beneath  this  roof,  which 
protects  the  general  peritoneal  cavity  from  contamination. 

3.  Better  drainage.  In  vaginal  section  the  opening  is  made  at  the  lowest 
part  of  the  pelvic  cavity — the  best  place  for  drainage. 

4.  Quicker  convalescence.  There  is  less  disturbance  of  the  intraabdominal 
structures.  Also  the  wound  is  smaller,  better  protected  and  supported  by 
surrounding  parts,  and  is  not  so  likely  to  be  followed  by  hernia. 

5.  No  visible  scar.  This  is  of  some  importance.  A  long  scar  marking 
the  site  of  a  former  opening  into  one's  interior  is  not  particularly  pleasant  for 
the  patient  to  contemplate.  It  is  an  ever-present  reminder  of  the  disease  that 
was  present  and  of  the  operation.  It  is  well  to  avoid  making  such  a  scar  in 
cases  where  other  methods  are  just  as  good. 

6.  Vaginal  section  combines  easily  with  certain  plastic  operations,  which 
are  sometimes  indicated  at  the  same  time. 

DISADVANTAGES 

The  disadvantages  of  vaginal  section  are : 

1.  Lack  of  room  in  the  operative  field.  The  manipulations  are  cramped 
and  are  carried  out  with  less  certainty  of  accomplishing  the  desired  result. 

2.  Imperfect  exploration  of  pelvis  and  lower  abdomen.  The  pelvic  struc- 
tures are  harder  to  reach  and  the  lower  abdominal  structures  (appendix,  etc.) 
can  not  be  satisfactorily  reached  at  all.  And  of  the  structures  reached,  the 
determination  of  their  condition  must  be  usually  made  almost  altogether  through 
the  sense  of  touch,  for  the  structures  can  be  only  imperfectly  exposed  to  sight. 

3.  Eemnants  remain.  \Yhere  the  adhesions  are  extensive  there  is  likely 
to  be  imperfect  work  unless  the  uterus  is  removed,  and  in  many  cases  it  is  not 
advisable  to  remove  the  uterus. 

4.  There  is  not  so  good  a  chance  to  determine  whether  or  not  the  condi- 
tions are  favorable  for  conservative  work  on  the  ovaries  or  tubes,  and  the 
work  itself,  when  indicated,  can  not  as  a  rule  be  so  satisfactorily  executed. 


1084  INVASION    OF    THE   PERITONEAL    CAVITY 

5.  Appendix  affections  can  not  be  satisfactorily  handled.  The  appendix 
is  diseased  and  requires  removal  in  a  considerable  proportion  of  patients 
with  pelvic  disease. 

SELECTION  OF  CASES 

The  operative  cases  in  which  the  author  considers  the  vaginal  operation 
preferable  to  the  abdominal  are: 

1.  Acute  infection  in  the  pelvis  that  has  not  yet  spread  to  the  general 
peritoneum.  This  acute  severe  pelvic  peritonitis  is  seen  principally  in  cases 
of  sepsis  following  labor  or  abortion.  If  general  peritonitis  is  present,  abdom- 
inal section  is  preferable. 

2.  A  collection  of  pus  low  in  the  pelvis  within  easy  reach  of  the  fingers, 
particularly  if  there  is  a  probability  that  the  general  peritoneal  cavity  is  well 
walled  off  above. 

3.  For  exploration  of  the  pelvis  in  certain  doubtful  cases  when  it  is  evident 
that  all  the  information  required  can  be  determined  from  below. 

The  operative  cases  in  which  the  author  considers  abdominal  section  pref- 
erable to  vaginal  section  include: 

1.  Chronic  inflammatory  lesions,  with  or  without  a  collection  of  pus. 

2.  Cases  of  adherent  retrodisplacement  of  the  uterus. 

3.  Cases  in  which  conservative  work  on  ovaries  or  tubes  is  probably 
required. 

4.  Ovarian  and  broad  ligament  and  uterine  tumors  (except  certain  fibroids 
that  can  be  satisfactorily  removed  from  below). 

5.  Extrauterine  pregnancy  (except  where  all  that  remains  is  a  walled-off 
hematocele), 

6.  Cases  complicated  Avith,  or  probably  complicated  with,  appendix  trouble. 

7.  Obscure  cases,  requiring  thorough  examination  of  the  pelvis  and  lower 
abdomen. 

PREPARATIONS 

For  Vaginal  Section 

The  preparations  for  vaginal  section  are  practically  the  same  as  for 
abdominal  section,  except  that,  in  the  preparation  of  the  operative  field,  the 
external  genitals  and  the  vagina  are  prepared  instead  of  the  abdomen. 

The  patient  receives  an  antiseptic  douche  one  to  three  times  daily, 
depending  upon  the  amount  and  character  of  the  discharge.  The  afternoon  or 
evening  before  the  operation  the  external  genitals  and  adjacent  surfaces  are 
shaved  and  then  carefully  scrubbed  with  green  soap  and  warm  water,  using 
cotton  balls  or  a  soft  brush.  The  vagina  also  is  cleansed  with  cotton  balls 
held  in  the  forceps.    This  cleansing  should  be  done  gently,  so  as  not  to  abrade 


CONSERVATIVE    SURGERY  1085 

the  vaginal  surface  and  thus  invite  infection  at  points  in  the  operative  field. 
No  alcohol  nor  ether  is  used  here,  as  it  would  cause  too  much  irritation. 
After  the  careful  cleansing  with  soap,  the  soap  is  cleared  away  Avitli  sterile 
Avater  and  the  vagina  and  external  genitals  are  cleansed  with  a  bichloride 
solution  (1-2000).  Some  prefer  to  pack  the  vagina  at  this  time  with  antiseptic 
gauze,  the  packing  to  remain  in  place  until  the  patient  is  anesthetized  for 
the  operation.  If  there  is  much  discharge,  however,  the  packing  holds  the 
discharge  in  the  vagina,  where  it  decomposes  more  or  less;  consequently,  in 
such  cases  the  packing  is  not  advisable. 

In  certain  complicated  cases  and  in  doubtful  cases  the  abdomen  also  should 
be  prepared,  as  it  may  be  necessary  to  employ  abdominal  section  in  order  to 
deal  satisfactorily  with  the  conditions  found. 

After  the  patient  is  under  the  anesthetic  the  external  genitals  and  vagina 
are  scrubbed  thoroughly  Avith  soap  solution  and  rinsed  with  sterile  water, 
then  dried  with  cotton-balls.  A  two  per  cent  solution  of  tincture  of  iodine  is 
then  dried  with  cotton  balls.  A  two  per  cent  solution  of  tincture  of  iodine  is 
walls.  The  discoloration  caused  by  the  iodine  is  readily  removed  by  washing 
with  a  cotton  ball  soaked  in  alcohol. 

STEPS 

In  Vaginal  Section 

The  steps  in  the  operation  are  essentially  the  same  as  for  abdominal  sec- 
tion, changing  the  field  from  the  abdominal  surface  to  the  depths  of  the  vagina. 
The  steps  are : 

1.  Anesthesia. 

2.  Exposure  of  operative  field  by  suitable  retractors. 

3.  Incision  and  entrance  into  the  peritoneal  cavity. 

4.  Exploration. 

5.  Correction  of  pathologic  condition. 

6.  Restoration  of  structures  to  approximately  normal  relations. 

7.  Closure  of  incision  or  drainage,  as  thought  preferable  in  that  par- 
ticular case. 

8.  Dressing. 

CONSERVATIVE  SURGERY 

of  the  Ovaries,  Tubes,  Uterus 

By  the  term  ''conservative  surgery"  is  meant  the  conserving  or  saving  of 
undiseased  portions  of  ovaries  and  tubes,  or  of  portions  that  are  somewhat 
affected,  but  not  enough  to  threaten  serious  trouble  should  they  be  left.  A 
''conservative  operation,"  then,  is  an  operation  that  saves  an  organ  or  part 
of  an  organ  that  would  otherAvise  (by  the  regular  radical  operation)  be  wholly 


1086  INVASION    OF    THE   PERITONEAL    CAVITY 

removed.  Conservative  surgery  of  the  ovaries  and  tubes  is  of  rather  recent 
development,  and  in  order  to  bring  it  before  you  in  its  proper  relation  the 
author  will  recall  briefly  the  steps  preceding  it. 

Before  the  eighteenth  century,  operation  for  the  removal  of  ovarian 
tumors  had  been  suggested  by  a  number  of  physicians,  but  it  had  never  been 
put  into  practice.  Later,  the  celebrated  John  Hunter  and  the  equally  cele- 
brated John  Bell  both  advocated  the  operation,  but  neither  of  them  ventured 
to  perform  it. 

The  first  ovariotomy  in  the  world  was  performed  by  Ephraim  McDowell, 
a  native  of  Virginia,  practicing  in  Kentucky.  McDowell  had  attended  the 
lectures  of  John  Bell  in  Edinburg  in  1749;  and  was  convinced  of  the  correct- 
ness of  his  teacher's  views  in  regard  to  the  removal  of  ovarian  tumors.  He 
returned  to  Kentucky  and  practiced  his  profession  mthout  special  incident 
until  1808,  when  he  was  confronted  by  a  case  of  ovarian  tumor  requiring 
operation.  After  giving  the  matter  careful  consideration  and  making  full 
explanation  to  the  patient,  he  performed  the  operation,  and  the  patient 
recovered.  From  that  time  the  practice  gradually  spread  over  the  civilized 
world,  and  after  half  a  century  ovariotomy  became  comparatively  frequent. 
The  ovaries  were  removed,  not  only  for  tumors,  but  for  all  sorts  of  ovarian 
diseases,  from  the  most  serious  to  the  most  trivial.  In  fact,  it  became  quite 
common,  later,  to  remove  practically  normal  ovaries  for  various  nervous  dis- 
turbances Avhich  it  was  thought  might  be  due  to  them  (Battey's  operation). 

After  a  time,  however,  it  began  to  da^vn  upon  the  profession  that  the 
ovaries  had  another  function  than  ovulation,  and  that  when  the  ovaries  were 
removed  the  patient  was  deprived,  not  only  of  ovulation,  but  also  of  some 
factor  which  has  a  marked  influence  on  the  general  health.  Gradually  the 
trophic  function  of  the  ovary,  explained  in  all  details  in  Chapters  xiv  and 
XV,  was  worked  out.  From  the  facts  thus  far  established  we  know  that, 
aside  from  the  consideration  of  ovulation  or  pregnancy,  an  ovary  should  be 
preserved  wherever  possible  on  account  of  the  influence  it  exerts  over  the 
patient's  health,  particularly  over  her  nervous  system. 

The  objects  for  which  conservation  is  thus  practiced  in  pelvic  surgery 
are  three : 

1.  Preservation  of  the  possibility  of  pregnancy.  To  make  pregnancy 
possible,  -there  must  be  one  ovary,  or  a  functionating  piece  of  one  ovary,  and  a 
patent  tube.  The  patent  tube  may  be  on  the  same  side  as  the  ovary  or  on  the 
opposite  side.  It  may  be  a  normal  tube  or  simply  the  open  stump  of  a 
tube,  the  remainder  of  the  tube  having  been  removed  on  account  of  some 
disease  (Fig.  791). 

Under  all  these  circumstances  pregnancy  is  possible  and  has  taken  place 
in  a  number  of  instances.  Of  course,  it  is  not  as  likely  to  take  place  as  in  a 
normal  individual,  but  still  the  patient  has  a  chance  of  becoming  pregnant. 
Another  point,  sometimes  overlooked,  is  that,  even  though  no  pregnancy 
results  from  these  efforts  at  conservatism,  the  simple  fact  that  the  patient 


CONSERVATIVE   SURGERY 


1087 


may  become  pregnant — that  pregnancy  is  still  possible — conduces  much  to  her 
peace  of  mind. 

2.  Another  effect  sought  by  conservative  pelvic  surgery  is  continuation  of 
menstruation.  Even  though  the  hope  of  pregnancy  must  be  sacrificed  on 
account  of  disease  necessitating  the  complete  removal  of  both  tubes,  if  an  ovary 
or  functionating  piece  of  an  ovary  can  be  left  in  the  pelvis  with  the  uterus, 
menstruation  continues,  though  pregnancy  is  impossible. 

3.  Still  another  effect  sought  by  this  conservative  surgery  is  the  continua- 
tion of  the  trophic  influence  of  the  ovary.  When  the  uterus  must  be  removed, 
pregnancy  and  menstruation  are  of  course  no  longer  possible.  However,  if 
an  ovary  or  a  functionating  piece  of  an  ovary  can  be  saved,  the  secretory 
influence  of  the  ovary  is  preserved,  provided  that  the  retained  portion  of  the 
ovary  continues  its  function;  i.  e.,  continues  to  form  corpora  lutea. 


Fig.  791.  Conservative  Surgery  of  Ovary  and  Tube.  Excision  of  damaged  portion  of  tube,  showing 
how  the  end  of  the  stump  is  split  and  sewed  open.  Excision  of  cyst  from  ovary,  with  preservation  of  the 
unaffected  portion  of  the  organ.     Lesions  shown  on  right  side  and  conditions  after  excision  on  the  left  side. 


This  latter  fact  must  be  kept  in  mind.  The  mere  leaving  of  a  portion  of  the 
ovary  does  not  insure  a  continuation  of  menstruation  or  of  the  trophic 
iniluence.  To  produce  the  desired  result,  the  portion  of  ovary  left  must  con- 
tinue to  functionate.  If  its  nutrition  is  so  interfered  with  that  ovulation  does 
not  continue,  it  is  just  the  same  as  though  no  ovarian  tissue  had  been  left. 
Some  time  ago  the  author  saw  a  woman  who  had  been  operated  on  in  a 
distant  city.  The  operator  had  told  her  that  she  would  menstruate,  as  part 
of  one  ovary  had  been  left  in  place.  Menstruation,  however,  ceased  entirely 
after  the  operation,  and  when  seen  by  the  writer  she  was  suffering  from  the 
symptoms  of  the  artificial  menopause.  She  was  inclined  to  think  that  both 
ovaries  had  been  completely  removed  and  to  blame  the  operator  for  "deceiv- 
ing" her.-  It  was  evidently,  however,  one  of  those  cases  in  which  the  portion 


1088  INVASION    OF    THE   PERITONEAL    CAVITY 

of  ovary  preserved  had  not  survived  in  condition  to  continue  its  functions, 
and  the  patient's  confidence  in  her  former  physician  was  restored  by  this 
explanation. 

4.  Another  form  of  conservative  work  is  the  preservation  of  a  part  of  the 
corpus  uteri  in  certain  fibroid  cases  ordinarily  subjected  to  supravaginal 
hysterectomy.  Instead  of  removing  all  of  the  uterus  except  the  cervix,  the 
amputation  of  the  affected  portion  is  made  so  as  to  preserve  the  loAver  part 
of  the  corpus.  Again,  the  uterus  may  be  split  in  the  median  line,  the  tumor 
and  affected  portion  removed  and  the  remaining  lateral  portions,  with  as 
much  endometrium  as  possible,  preserved  and  sutured  together.  In  this 
way  the  preservation  of  menstruation,  which  is  an  important  matter  in  young 
women,  may  be  attained  in  certain  cases. 

Conservative  pelvic  surgery  in  its  various  forms  is  still  in  the  develop- 
mental stage.  As  more  and  more  of  this  conservative  work  is  done  and  remote 
results  recorded,  we  shall  be  able  to  determine  more  accurately  its  limitations, 
and  to  say  in  just  what  conditions  it  is  advisable  and  in  what  conditions  not 
advisable. 


CHAPTER  XVII 

AFTER-TREATMENT  IN  OPERATIVE  CASES 

ABDOMINAL  SECTION 

The  details  of  the  care  of  a  patient  after  abdominal  section  may  be  divided 
into  (A)  the  regular  after-treatment  and  (B)  the  care  in  special  conditions. 

(A)     REGULAR  AFTER-TREATMENT 

First  Day.  During  the  operation  the  bed  which  the  patient  is  to  occupy 
should  be  warmed  with  hot-water  bottles  placed  under  the  blankets.  When 
the  patient  is  placed  in  bed  the  hot-w^ater  bottles  are  distributed  about  her, 
to  maintain  the  heat  and  diminish  shock.  Care  should  be  taken  that  there 
is  no  leakage  from  any  bottle,  and  that  a  thick  blanket  is  everywhere  between 
the  hot  bottles  and  the  patient.  Much  discomfort  and  even  serious  injury 
may  foUoAV  a  burn  from  a  hot  water  bottle,  caused  by  the  bursting  of  a  bot- 
tle or  leakage  from  a  bottle,  or  a  too  thin  protective  covering  between  the  bot- 
tle and  the  patient.  In  several  instances  legal  complications  have  resulted, 
involving  the  nurse  or  the  hospital,  or  the  physician. 

The  patient's  head  should  be  low  (no  pillow  under  it)  until  she  has 
recovered  from  the  anesthetic.  Keep  the  patient  quiet  and  let  her  sleep  as  long 
as  she  will  from  the  anesthesia.  If  the  patient  vomits,  she  should  be  turned 
well  over  on  the  side  to  cause  the  vomited  material  to  run  out  of  the  throat, 
that  there  may  be  no  chance  of  its  getting  into  the  larynx  and  choking  her. 
Death  may  occur  from  this  cause.  To  diminish  the  thirst,  swab  the  interior 
of  the  mouth  frequently  (when  the  patient  is  awake)  with  cold  water,  either 
plain  or  acidulated  with  a  few  drops  of  vinegar  or  lemon  juice. 

The  orders  for  the  first  day  are  usually  about  as  follows : 

If  in  much  pain,  give  codeine  phosphate  %  gr.  to  %  gr.  hypod.,  and  repeat  after  two 

hours  as  necessary  to  give  rest. 
If  vomiting,  turn  well  on  one  side. 
May  have  water  as  soon  as  she  wishes  it — hot  or  cold,  as  best  retained,  half  an  ounce 

every  fifteen  minutes  when  desired,  unless  vomiting  persistently. 
Catheterize  only  if  necessary.     When  bladder  tills,   employ  usual  expedients  to  assist 

urination   (propping  up  in  bed,  warm  water  to  genitals,  pressure  on  bladder,  etc.). 

It  is  not  necessary  ordinarily  for  the  patient  to  be  kept  strictly  on  her 
back.  After  a  few  hours,  if  very  tired  of  the  one  position,  she  may  be  propped 
partly  to  one  side  or  the  other  occasionally.    But  she  must  not  be  allowed  to 

1089 


1090  AFTER-TREATMENT  IN  OPERATIVE  CASES 

develop  that  restlessness  that  insists  on  constantly  changing  from  one  side 
to  the  other  in  an  endeavor  to  find  a  comfortable  position.  No  position  is  very 
comfortable  under  the  circumstances  and  the  too  frequent  changing  increases 
the  discomfort. 

The  patient  should  be  quieted  as  much  as  possible  without  medicine,  in 
order  that  the  administration  of  sedatives  may  be  avoided  or  kept  within  small 
amount.  The  nurse  can  do  much,  by  arranging  the  patient  comfortably  in 
bed  and  directing  her  frequently  to  keep  the  eyes  closed  and  to  nap  as 
much  as  possible.  If  there  is  such  severe  pain  that  the  codeine  does  not  give 
rest,  morphia,  in  Yq  gr.  doses,  may  be  given,  but  that  is  rarely  necessary. 
If  preferred,  the  sedative  may  be  given  by  suppositories,  but  its  effect  is  not 
so  prompt  and  can  not  be  so  accurately  graduated. 

As  a  rule  the  author  ]3refers  to  let  the  patient  have  water  in  small  doses 
as  soon  as  she  wishes  it.  It  diminishes  the  thirst  and  helps  to  supply  the  sys- 
tem with  needed  fluid.  Occasionally  vomiting  does  no  harm;  rather  it  is  benefi- 
cial in  that  it  helps  to  clear  out  the  ether-saturated  mucus,  the  retention  of 
which  increases  stomach  irritation  and  disturbance.  If  there  is  persistent 
vomiting,  and  especially  if  there  is  persistent  epigastric  pain,  a  stomach- tube 
should  be  introduced  and  the  stomach  washed  out  with  a  quart  of  normal 
saline  solution.  This  stomach  washing  (lavage)  has  come  to  be  recognized  as 
a  most  important  measure  in  postoperative  treatment.  It  is  the  only  effective 
treatment  for  the  serious  complication  of  acute  dilatation  of  the  stomach 
(page  1099),  and  in  any  case  of  persistent  stomach  irritation  it  adds  much  to  the 
patient's  comfort  by  clearing  out  the  irritating  material. 

If  the  patient  can  not  take  water  by  mouth,  the  thirst  may  be  diminished 
by  saline  solution  per  rectum  by  the  drop  method  (proctoclysis).  If  the 
patient  is  in  shock,  start  the  proctoclysis  and  employ  the  other  measures  for 
that  condition  (page  1098). 

Second  Day.  During  the  second  day  the  orders  previously  given  are  con- 
tinued unless  there  is  some  special  reason  for  modifying  them.  The  patient 
may  take  water  more  freely,  and  the  liquid  nourishment  is  now  begun  and 
gradually  increased  as  the  stomach  will  bear  it.  For  this  purpose  peptonized 
milk  may  be  used,  or  milk  and  limcAvater  (half  and  half),  or  albumen  water 
or  beef  tea — one  or  two  ounces  about  every  two  hours,  hot  or  cold  as  best 
retained. 

If  the  patient  has  to  be  catheterized,  it  is  well  to  give  some  reliable  urinary 
antiseptic  to  diminish  the  danger  of  cystitis.  If  gas  in  the  intestines  is 
troublesome,  a  rectal  tube  may  be  introduced.  If  the  operation  was  an 
emergency  one,  where  there  was  no  opportunity  for  preliminary  preparation 
of  the  intestinal  tract,  it  may  be  advisable  to  secure  a  bowel  movement 
within  the  second  twenty-four  hours,  in  which  case  the  calomel  is  now  begun. 
Ordinarily,  however,  this  is  preferably  postponed  until  the  third  day. 

Third  Day.  At  the  beginning  of  the  third  day  start  the  patient  on  the 
purgative  regimen,  indicated  below,  that  a  bowel  movement  may  be  secured 


APTER-TREATMENT  IN   ABDOMINAL   SECTION  1091 

some  time  during  this  twenty-four  hours.  If  the  quantity  of  urine  is  good, 
the  frequency  and  duration  of  the  proctoclysis  (if  it  is  being  used)  may  be 
reduced. 

The  orders  for  the  third  day  are  usually  about  as  follows : 

Calomel  %  gr.  every  half  hour  till  eight  doses  are  taken.  Four  hours  after  last  dose 
of  calomel  give  a  high  enema  of  magnesium  sulphate  (1  oz.),  glycerine  (2  oz.) 
and  -water   (4  oz.).     This  is  to  be  retained  twenty  minutes  if  possible. 

If  there  is  not  a  satisfactory  bowel  movement  from  this  enema,  give  the  patient  a 
teaspoonful  of  Eochelle  salt  every  two  hours  till  three  doses  are  taken,  and  four 
hours  after  the  last  dose  repeat  the  magnesium  sulphate  enema. 

Continue  the  codeine  if  necessary  to  give  rest. 

Urotropin  5  gr.  in  two  ounces  of  water  every  eight  hours. 

Fourth  Day.  Ordinarily  by  this  time  one  or  two  good  bowel  movements 
have  been  secured,  and  the  patient  has  become  fairly  comfortable.  If  the 
kidneys  are  secreting  well,  the  proctoclysis  may  be  stopped.  All  medicines  may 
now  be  given  by  mouth.  The  patient  may  be  propped  up  as  necessary,  to  aid 
in  urination  if  she  is  not  already  urinating.  Some  semisolid  and  solid  arti- 
cles of  diet  (custards,  breakfast  foods,  toast,  crackers,  bread,  etc.)  may  be 
allowed.  As  a  rule,  no  sedative  is  now  necessary,  except  an  occasional  dose 
of  sodium  bromide  when  the  patient  is  particularly  restless  at  night.  It  is 
well  to  start  the  patient  on  some  good  iron  tonic,  for  these  patients  are 
usually  anemic.  Tincture  of  the  chloride  of  iron,  with  care  in  giving,  is 
excellent.  If  preferred,  some  one  of  the  numerous  organic  iron  preparations 
may  be  used.  If  adhesive  strips  have  been  put  on  at  the  first  dressing,  remove 
them  now,  so  that  the  skin  will  be  in  good  condition  for  the  other  strips  to 
be  put  on  when  the  sutures  are  removed. 

The  orders  given  at  this  time  may  serve  as  standing  orders,  to  be  continued 
as  long  as  the  patient  is  in  the  hospital,  except  when  modified  for  some 
special  indications.     They  are  about  as  follows: 


Strychnia  sulphate,  1-40  gr.  in  a  capsule,  three  times  daily,  after  meals. 

Tincture  ferri  chloridi,  10  drops  in  a  capsule,  three  times  daily,  after  meals. 

Light  diet,  with  extras.  Push  the  nourislunent.  Give  an  abundance  of  water  and 
of  liquid  nourishment.    Articles  from  the  regular  diet  may  be  added  as  desired. 

Urotropin,  5  gr.  in  half  a  glass  of  water,  twice  daily.  Laxative  pill  (aloin,  bella- 
donna, strychnia  and  cascara)  one  each  night,  unless  bowel  movements  are  too 
frequent. 

Give  an  enema  when  no  bowel  movement  during  day. 

Subsequent  Orders.  It  is  well  to  continue  the  urinary  antiseptic  for  a 
week  after  the  urine  is  passed  spontaneously.  The  diet  is  gradually  increased 
until  the  patient  is  taking  regular  diet  with  extras.  She  should  continue  to 
take  liquid  nourishment  between  meals. 

If  during  convalescence  the  patient  does  not  take  and  digest  sufficient 
food,  the  digestive  powers  may  be  increased  by  massage,  salt  rubs,  passive 
movements    and    resisted   movements,    judiciously    administered    by    a    com- 


1092 


AFTER-TREATMENT   IN    OPERATIVE    CASES 


petent  nurse.  The  careful  carrying  out  of  the  regular  nursing  given  bed 
patients  (including  the  daily  morning  bath  and  evening  alcohol  rub)  is  also 
an  important  factor  in  causing  the  patient  to  be  comfortable  and  to  rest  vs^ell 
at  night,  and  to  digest  her  food  promptly.  If  there  is  any  decided  digestive 
disturbance,  some  remedy  for  that  should  of  course  be  given. 

Removing  the  Sutures.  Unless  there  is  some  indication  of  irritation  in 
the  wound,  the  dressing  is  not  to  be  disturbed  for  ten  days.  Then  it  is  taken 
off  and  the  sutures  removed.  The  wound  is  now  healed.  The  vicinity  of  the 
wound  is  dusted  freely  Avith  boric  acid  powder,  a  smooth  piece  of  gauze  (sev- 


Fig.   792.      Strapping  the   Abdomen   after   removing   the    sutures. 


eral  thicknesses)  is  laid  over  the  scar,  and  the  abdomen  is  strapped  with 
strips  of  two-inch  adhesive  plaster  (Fig.  792) 'in  such  a  way  as  to  take 
the  strain  from  the  newly  healed  wound.  Four  to  six  strips  are  put  on 
so  as  to  give  firm  support.  Then  a  piece  of  cotton  is  placed  over  all  and  the 
binder  reapplied. 

The  adhesive  strips  are  usually  left  undisturbed  for  about  a  week.  If  it  is 
desired  to  look  at  the  wound  area,  because  of  irritation  along  the  suture 
tracts  or  for  other  reason,  the  adhesive  plaster  is  cut  along  the  edges  of  the 
gauze  (Fig.  793)   and  the  gauze  removed  so  that  the  scar  and  vicinity  are 


APTER-TREATMENT   IN   ABDOMINAL    SECTION 


1093 


exposed.  (Fig.  734).  After  the  required  treatment,  gauze  is  again  applied 
and  then  new  plaster  put  on,  the  ends  of  the  new  plaster  adhering  to  the 
old  plaster  at  each  side.  This  permits  inspection  of  the  wound  area  as  often 
as  desired  without  the  discomfort  of  repeated  removal  of  plaster  from  the 
skin. 

Ordinarily,  however,  the  adhesive  strips  need  not  be  disturbed  for  a  week. 
In  the  meantime  a  strong,  light-weight  abdominal  supporter  is  fitted  to  the 
patient.  It  is  well  to  leave  the  adhesive  strips  on  until  the  patient  reaches 
home,  as  they  serve  as  an  additional  protection  during  the  extra  exertion 
of  the  trip.  After  the  patient  reaches  home  and  the  abdominal  supporter 
has  become  comfortably  adjusted,  the  adhesive  strips  are  taken  off.     The 


Fig.  793.     Cutting  the  Plaster,  so  as  to  inspect  the  wound  and  change  the  gauze  without  removing  the 

plaster  from  the  skin. 


supporter  is  to  be  worn  for  about  three  months,  but  only  when  the  patient 
is  up  and  about.  It  may  be  taken  off  at  night.  Some  authorities  recommend 
that  no  abdominal  supporter  or  binder  be  worn.  But  while  most  patients 
get  along  very  well  without  it,  the  author  feels  that  it  is  a  precaution  which  it 
is  well  to  employ.  It  is  of  decided  benefit  in  some  cases  (where  the  abdominal 
wall  is  lax  and  protuberant)  ;  it  adds  to  the  patient's  comfort  in  most  cases,  it 
reminds  the  patient  of  the  necessity  of  avoiding  overexertion  in  all  cases, 
and  it  does  no  harm  in  any  case  if  waist  constriction  be  avoided. 

Sitting  Up,  Walking".     Unless  there  is  some  special  reason  for  hurrying 
the  patient  to  the  sitting  posture,  she  should  be  allowed  to  remain  quiet  and 


1094 


AFTER-TREATMENT   IN    0PERATI\T:    CASES 


in  the  recumbent  postnre  for  the  first  few  days.  After  the  bowels  have 
moved  well,  the  patient  should  be  encouraged  to  move  about  in  the  bed  and  to 
be  propped  up  as  much  as  she  likes — more  and  more  each  day — so  that  by  the 
end  of  the  first  week  she  is  ready  to  sit  out  of  bed  and  begin  walking.  The 
advantages  of  this  early  moving  about  in  the  bed  and  early  getting  up  are 
better  circulation  (less  "bed -weakness"),  and  consequently  better  repair  of 
wounds,  better  digestion  and  quicker  restoration  to  normal  condition. 

It  is  not  advisable,  however,  to  get  the  patient  up  too  early,  while  Nature 
is  still  fully  occupied  with  the  acute  repair  work  of  the  first  few  days.  The 
feeling   of  the  patient  is.   as   a   rule,   the  best   guide   as   to   when   to   begin 


Fig.  794.  Method  of  Exposing  the  Wound  as  often  as  necessary  for  change  of  dressing,  without 
causing  the  patient  the  discomfort  of  repeated  removal  of  plaster  from  the  skin.  The  new  plaster  is  put 
over  the  old. 


actiAdty.  The  plan  just  described  is  decidedly  preferable  to  the  "hurrj^  up" 
method  of  getting  the  patient  out  of  bed  in  one  to  two  days,  which  was  recently 
so  popular  with  some.  In  cases  where  the  patient  will  be  benefited  by 
further  rest,  do  not  hesitate  to  keep  her  in  bed  ten  days  or  two  weeks,  or 
even  longer.  In  many  instances  the  patient  is  greatly  debilitated  and  literally 
"worn  out"  by  chronic  sepsis  or  by  months  of  suffering  and  ill-health,  or  by 
heroic  work  for  her  children  in  spite  of  failing  strength.  In  all  these  cases, 
the  enforced  rest  in  bed  may  be  an  important  aid  in  restoring  the  patient's 
health. 


AFTER-TREATMENT   IN    ABDOMINAL   SECTION  1095 

After  the  patient  has  returned  to  her  home,  the  tonic  medicines  and 
regimen  should  be  kept  up  for  three  to  six  months,  as  necessary,  to  put  the 
patient  in  first-class  general  health. 

(B)     SPECIAL  CONDITIONS 

1.  Drainage  Cases.  AVhen  a  glass  tube  is  left  extending  into  the  pelvis 
for  drainage,  a  large  piece  of  sterile  sheet-rubber  is  usually  slipped  over 
the  end  of  the  tube  to  keep  the  iluid  that  comes  out  of  the  tube  from  soiling 
the  gauze  on  the  abdominal  wound.  A  small  wick  of  tmsted  gauze  is  then 
passed  to  the  bottom  of  the  tube  to  aid  in  the  drainage.  This  twisted 
wick  should  be  small  enough  to  leave  plenty  of  room  around  it  inside  the 
tube  to  permit  the  discharge  to  come  out.  Some  pieces  of  gauze  are  now 
placed  over  the  end  of  the  tube  and  the  piece  of  sheet-rubber  is  folded 
over  the  gauze  from  all  sides.  The  whole  is  then  covered  with  a  large 
piece  of  sterile  cotton  and  the  binder  applied,  taking  care  to  avoid  pressing 
on  the  tube.  This  is  the  technic  ordinarily  employed  in  the  dressing  at  the 
time  of  the  operation. 

The  frequency  with  which  the  drainage  tube  must  be  dressed  varies  Avith 
the  amount  of  drainage  fluid.  In  chronic  cases,  where  the  pelvis  is  left  fairly 
dry,  the  amount  of  fluid  is  usually  small.  It  is  well  to  dress  the  tube  within 
three  to  six  hours,  or  before  if  there  is  a  probability  of  much  oozing  or  secre- 
tion. The  frequency  of  the  subsequent  dressing  is  regulated  by  the  amount 
of  fluid  found.  The  idea  is  to  change  the  dressing  before  all  the  gauze  con- 
fined in  the  rubber-dam  becomes  filled  with  absorbed  fluid.  Usually  every 
eight  to  tAvelve  hours  is  sufficient  for  the  first  tv^o  days  and  after  that  once 
daily. 

In  cleansing  and  dressing  the  tube  the  strictest  asepsis  must  be  observed. 
The  instruments  needed  are  simply  a  long  probe  or  applicator,  for  pushing 
the  gauze  wick  to  the  bottom  of  the  tube,  and  a  scissors  for  cutting  the  gauze. 
These  instruments  should  be  boiled,  and  in  addition  to  the  ordinary  disin- 
fection of  the  hands  it  is  well  to  wear  sterilized  rubber  gloves  (Fig.  795). 
After  the  preparation  of  the  instruments  and  of  the  physician's  hands,  the 
binder  and  outer  part  of  the  dressing  are  removed  by  the  nurse,  thus  expos- 
ing the  sterile  sheet-rubber.  The  physician  then  unfolds  the  sheet-rubber  and 
removes  the  gauze  therein  and  also  the  saturated  gauze  wick  in  the  tube. 
Another  gauze  wick  is  then  twisted,  taking  care  to  remove  all  loose  ravel- 
ings.  The  end  of  this  sterile  wick  is  then  pushed  to  the  bottom  of  the  tube 
and  left  there  for  a  minute  to  absorb  the  discharge.  It  is  then  removed  and  a 
fresh  one  introduced.  This  process  is  repeated  until  all  the  fluid  in  the  tube 
is  removed.  A  fresh  wick  is  then  introduced  and  gauze  is  placed  about  the 
end  of  the  tube,  and  the  sheet-rubber  folded  over  as  before.  The  inner  sur- 
face of  the  rubber-sheeting  should  be  cleansed  with  some  reliable  antiseptic 
solution    (e.  g.,    bichloride,    1-2000)    and   the    interior    of   the    tube   may  be 


1096 


AFTER-TEEATMENT   IN"   OPERATIVE    CASES 


cleansed  witli  a  gauze  wick  wrung  out  of  the  same  solution.  Also,  the  tube 
should  be  raised  slightly  and  rotated  once  daily,  in  order  to  prevent  injurious 
pressure  on  the  rectum  (which  might  cause  perforating  ulceration)  and  to 
prevent  stopping-up  of  the  drainage  holes  by  omentum  or  bowel,  or  exudate. 
The  tube  is  removed  when  the  collection  of  fluid  in  the  pelvis  ceases — that 
is,  in  two  to  five  days.  In  suppurative  cases  the  secretion,  of  course,  keeps 
up  indefinitely.  In  such  a  case,  the  tube  is  left  in  until  all  acute  threatening 
symptoms  have  disappeared  and  until  a  good  wall  has  formed  about  the  tube 
tract,  shutting  it  off  from  the  general  peritoneal  cavity.  It  may  as  a  rule  be 
removed  in  four  to  six  days,  and  a  small  rubber  tube  or  piece  of  gauze 
inserted  into  the  tract  to  keep  the  outer  end  open  until  it  closes  from  the  bot- 


Fig.  795.     Dressing  the  Drainage  Tube.     Articles  required — applicator,   scissors  and  pair   of   rubber   gloves. 


tom.  The  treatment  of  such  a  tract  is  to  keep  it  clean  by  cleansing  (daily 
or  less  frequently,  as  needed)  with  hydrogen  peroxide,  keeping  the  outer 
end  open  as  mentioned,  and  pi'oteeting  it  from  secondary  infection  by  an 
antiseptic  dressing.  It  is  well  to  keep  some  antiseptic  drying  powder  (e.  g., 
boric  acid)  dusted  freely  on  the  wound  about  the  drainage  tube. 

In  acute  cases,  where  there  is  virulent  infection  and  free  secretion,  the 
tube  must  be  cleansed  very  frequently- — as  often  as  every  two  or  three  hours  at 
first.  In  these  cases,  where  the  fluid  is  abundant,  the  removal  of  it  from  the 
tube  is  preferably  accomplished  with  a  syringe.  A  very  convenient  arrange- 
ment for  this  purpose  is  the  ordinary  hard  rubber  syringe  with  a  soft  rubber 


AFTER-TREATMENT   IN   ABDOMINAL   SECTION  1097 

catheter  attached.  It  is  more  convenient  to  handle  when  only  two-thirds  of 
a  catheter  is  nsed,  as  sho-\\Ti  in  Fig.  796.  In  the  very  acute  cases,  where 
drainage  in  various  directions  is  required  and  it  is  necessary  to  leave  the 
wound  partly  open,  the  whole  dressing  soon  becomes  soiled  Avith  the  dis- 
charge and  consequently  must  be  changed  frequently.  In  fact,  in  some  of 
these  cases  it  is  advisable  to  employ  warm  moist  dressings  (wrung  out  of 
normal  saline  solution  or  boric  acid  solution,  3  per  cent)   all  over  the  abdo- 


Fig.   796.      Syringe  and  part  of  a  catheter,  for  removing  large  amount   of  fluid  from  drainage  tube. 

men  and  wound,  the  moist  dressing  to  be  changed  every  few  hours,  or  as 
often  as  it  absorbs  a  considerable  amount  of  the  septic  discharge. 

"When  rubber  tubing"  is  used  for  drainage,  it  may  be  used  alone  or  with 
gauze  around  the  tube  or  as  the  "split-tube  with  gauze."  In  the  latter  a 
piece  of  large  rubber  tubing  is  split  longitudinally  and  a  small  wick  of 
twisted  gauze  laid  inside,  but  the  gauze  wick  must  be  small  enough  to  per- 


1098  AFTER-TREATMENT   IN    OPERATIVE    CASES 

mit  the  free  escape  of  fluid  through  the  tube.  Rubber-tube  drains  are  left 
in  until  the  necessity  for  drainage  has  disappeared  and  the  drainage  tract 
is  largely  closed  from  the  bottom.  Where  the  rubber  tube  is  of  large  size, 
it  is  removed  after  a  few  days  and  a  smaller  size  introduced. 

When  gauze  is  used  for  drainage,  alone  or  with  rubber  tubing,  it  is 
removed  usually  in  two  to  four  days. 

In  all  drainage  cases,  except  where  the  patient  is  in  severe  shock,  the 
upper  part  of  the  body  should  be  raised  higher  than  the  pelvis,  so  as  to 
cause  all  septic  fluid  in.  the  peritoneal  cavity  to  gravitate  to  the  pelvis,  where 
it  is  removed  through  the  drainage  tube.  Immediately  after  the  operation 
raise  the  head  of  the  bed  about  two  feet.  After  the  patient  has  recovered 
from  the  anesthetic  she  may  be  propped  up  in  the  half-sitting  posture  (Fowler 
posture). 

In  acute  septic  cases  normal  saline  solution  should  be  used  freely  per  rec- 
tum, as  described  on  page  829. 

2.  Uterine  Replacement  Cases.  The  principal  special  point  in  the  care 
of  the  patient  after  any  operation  for  fastening  the  uterus  and  adnexa  for- 
ward, is  to  see  that  the  bladder  is  not  allowed  to  fill  sufficiently  to  force 
the  uterus  backward  again  in  the  first  few  days  following  operation.  If  the 
patient  can  not  urinate,  she  should  be  catheterized  often  enough  to  prevent 
injurious  distention. 

3.  Severe  Shock.  When  the  patient  is  in  severe  shock,  the  head  should  be 
lowered  by  the  elevation  of  the  foot  of  the  bed  about  two  feet,  except  in  those 
cases  where  there  is  danger  of  spreading  pus  from  the  pelvis  to  the  upper  part 
of  the  uncontaminated  peritoneal  cavity. 

Give  the  patient  digitalin  ^o  gi"-  every  two  hours  and  strychnia  sulphate 
^0  S^-  every  four  hours  until  reaction  comes  on.  Still  more  important 
is  the  free  use  of  normal  saline  solution  by  proctoclysis.  If  the  shock  is 
extreme,  saline  solution  may  be  given  also  subcutaneously,  one  or  two  pints 
under  the  skin  of  the  chest  on  one  or  both  sides.  If  a  very  large  quan- 
tity of  blood  has  been  lost  and  the  pulse  is  thready  and  almost  gone,  a  pint 
to  a  pint  and  a  half  of  saline  solution  may  be  given  intravenously.  The  use 
of  oxygen  is  an  additional  measure  of  value  in  cases  where  respiration  is 
defective. 

The  hot  water  bottles  must  be  renewed  as  necessary  to  keep  the  patient 
warm,  and  the  proctoclysis  and  other  treatment  should  be  given  in  such  a 
way  as  to  avoid  chilling  of  the  surface. 

4.  Internal  Hemorrhage.  A  serious  internal  hemorrhage  is  indicated  by 
rapid  weakening  of  the  pulse,  an  increase  of  pain  in  the  abdomen  and  sub- 
normal temperature.  It  is  rare  after  the  first  twelve  hours,  and  usually 
comes  within  the  first  six  hours.  If  there  is  a  drain  through  the  abdominal 
incision  or  into  the  vagina,  there  will  be  a  free  flow  of  bloody  serum,  or,  if 
it  is  a  tube  drain,  of  blood  itself. 

The  treatment  of  a  slight  hemorrhage  is   (a)   to  elevate  the  pelvis  by 


AFTER-TREATMENT   IN   ABDOMINAL   SECTION  1099 

raising  the  foot  of  the  bed  (b)  to  put  an  ice  bag  on  the  pelvis  outside 
the  dressing,  (c)  to  keep  the  patient  perfectly  quiet  on  her  back,  and  (d) 
to  give  a  sedative  (codeine)  if  necessary  to  secure  rest.  Discontinue  the 
normal  saline  enemata,  as  the  pelvic  disturbance  occasioned  thereby  may 
increase  the  hemorrhage  or  start  it  after  it  had  once  ceased.  Do  not  give  any 
stimulants  or  employ  any  measure  that  will  increase  the  blood  pressure. 
The  hope  is  that,  as  the  blood  pressure  is  low,  the  bleeding  will  cease  for  a 
few  hours — long  enough  to  permit  effective  clotting  to  take  place  in  the 
oozing  area.  In  twenty-four  hours  such  clots  become  so  firm  that  a  renewal 
of  the  bleeding  is  not  probable. 

When  the  hemorrhage  is  severe,  the  abdomen  should  be  promptly  reopened 
(if  the  patient  is  seen  in  time)  and  the  bleeding  vessel  caught. 

5.  Persistent  Vomiting.  To  make  the  nausea  and  vomiting  as  slight  as 
possible,  the  patient's  head  should  be  low  (no  pillow)  for  several  hours 
after  anesthesia.  For  the  first  day  the  patient  should  be  kept  perfectly  quiet, 
with  the  eyes  closed  most  of  the  time,  so  as  to  nap  as  much  as  possible.  The 
nausea  is  increased  by  talking  or  by  even  looking  about.  If  a  visitor  is 
allowed,  it  should  be  for  only  a  few  minutes  and  there  should  be  but  little 
talking.  When  water  is  begun,  it  is  preferable  usually  to  give  hot  water, 
in  tablespoonful  doses  and  frequently,  though  some  patients  retain  cold 
Avater  very  well  from  the  first.  When  the  nausea  and  vomiting  is  such  that 
the  patient  can  not  rest,  give  codeine  phosphate,  1/2  to  %  gr.  hypodermically, 
and  repeat  after  three  hours,  as  necessary  to  give  rest. 

The  most  effective  measure  for  overcoming  vomiting,  persistent  nausea, 
and  stomach  distress  generally  is  washing  out  of  the  stomach  with  normal 
saline  solution,  as  described  on  page  1090.  After  the  bowels  are  well  opened 
the  vomiting  usually  ceases  unless  there  is  some  serious  complication,  such 
as  beginning  peritonitis  or  intestinal  obstruction,  both  of  which  are  men- 
tioned later. 

6.  Acute  Dilatation  of  Stomach.  This  is  a  serious  complication  that  may 
develop  any  time  after  operation,  but  especially  within  the  first  sixty  hours. 
The  patient  complains  of  persistent  pain  in  the  epigastric  region,  and  this 
region  becomes  more  or  less  distended.  The  pulse  becomes  rapid  and  weak 
without  apparent  cause.  There  is  usually  nausea  and  vomiting,  but  the  most 
constant  and  characteristic  signs  are  the  persistent  epigastric  pain  and  the 
failing  pulse.  The  anatomic  change  is  overdistention  of  the  stomach  with 
gas,  due  to  different  causes  in  different  cases.  In  the  majority  of  cases  it  is 
probably  due  to  some  displacement  of  the  stomach,  with  kinking  and  obstruc- 
tion at  the  pylorus.  As  the  gas  can  not  escape,  its  continued  accumulation 
becomes  a  serious  matter,  and  in  several  instances  death  has  resulted  from 
overdistention  of  the  stomach  caused  thereby. 

The  treatment  for  this  condition  is  prompt  introduction  of  the  stomach- 
tube,  to  permit  the  gas  to  escape,  and  irrigation  of  the  stomach  with  normal 
saline  solution  to  remove  all  decomposing  material  and  prevent  reaccumula- 


1100  AFTER-TREATMENT   IN    OPERATIVE    CASES 

tion  of  the  gas.  This  complication  should  be  watched  for  and  recognized,  and 
the  stomach-tube  used  before  it  reaches  a  serious  stage.  If  the  trouble  recurs, 
several  stomach  washings  may  be  required.  It  is  well  also  to  vary  the  patient's 
position,  so  as  to  overcome  displacement  of  the  stomach  and  dragging  on 
its  supports.  In  some  cases  it  seems  that  the  Fowler  posture  before  patient 
has  completely  awakened  from  the  anesthesia,  becomes  a  factor  in  the  develop- 
ment of  this  condition. 

7.  Kidney  Insufficiency.  This  is  more  easily  prevented  than  treated  after  it 
once  develops.  The  preventive  measure  is  to  make  sure  that  the  kidneys  are 
doing  their  work  well  before  operation.  The  treatment  for  kidney  insuffi- 
ciency after  operation  consists  in  the  free  administration  of  normal  saline 
solution  by  proctoclysis,  in  elimination  by  means  of  free  bowel  movements, 
and  sweat  packs  and  such  other  measures  as  are  used  for  the  regular  treat- 
ment of  uremic.  In  urgent  cases,  the  normal  saline  solution  may  be  given 
subcutaneously  or  even  intravenously. 

8.  Constipation  and  Intestinal  Paralysis.  When  the  purgative  measures, 
given  under  the  regular  after-treatment  (page  1090),  fail  to  cause  bowel  move- 
ment, the  loss  of  function  may  be  due  simply  to  temporary  paralysis  of 
the  bowel  or  to  intestinal  obstruction,  or  to  beginning  peritonitis.  Unless 
there  are  decided  evidences  of  intestinal  obstruction  or  peritonitis,  it  is  to  be 
assumed  that  the  trouble  is  temporary  intestinal  paralysis,  and  treatment 
for  the  same  is  begun.  The  treatment  consists  in  giving  strychnia,  in  giv- 
ing repeated  doses  of  purgatives,  such  as  compound  cathartic  pills  or  mag- 
nesium sulphate  by  mouth,  and  in  administering  enemata  that  tend  to  stimu- 
late the  bowels  to  action.  A  tablespoonful  of  turpentine  may  be  added  to 
the  magnesium  sulphate  enema  already  mentioned.  Or  the  patient  may  be 
given  a  high  enema  of  half  an  ounce  each  of  ox-gall  and  turpentine  in  a  pint 
of  water,  to  be  retained  as  long  as  possible.  Eserin  salicylate  has  seemed  to 
assist  in  stimulating  intestinal  peristalsis  in  some  cases — %o  gi"-  hypod.,  and 
repeat  after  four  hours  if  no  effect.     Pituitrin  should  be  tried,  1  c.c.  hypod. 

9.  Intestinal  Obstruction.  This  is  indicated  by  the  combination  of  per- 
sistent vomiting,  absence  of  bowel  movement  in  spite  of  the  use  of  the  purga- 
tive measures  already  mentioned,  severe  cramp-like  pains  in  the  abdomen 
recurring  every  few  minutes,  a  serious  rise  in  the  pulse  rate,  and  the  absence 
of  fever,  such  as  would  be  caused  by  peritonitis  of  sufficient  severity  to  give 
rise  to  the  other  symptoms.  Later  there  is  fecal  vomiting.  Such  a  combina- 
tion of  symptoms  calls  for  immediate  reopening  of  the  abdomen,  and  relief 
of  the  obstruction.  Unless  this  is  carried  out  promptly,  there  will  develop  a 
peritonitis  which,  in  combination  with  the  obstructive  trouble,  is  very  likely 
to  prove  fatal  in  spite  of  later  operation. 

10.  Peritonitis.  This  is  indicated  by  the  combination  of  symptoms  consist- 
ing of  fever  (beginning  or  increasing  after  the  second  day),  persistent  vomit- 
ing (extending  into  the  fourth  and  fifth  days),  serious  increase  in  the  pulse 
rate,  steady  pain  in  the  abdomen  (without  the  cramp-like  pains  of  intestinal 


AFTER-TREATMENT   IN   ABDOMINAL   SECTION  1101 

obstruction),  and  an  increasing  tenderness  in  the  lower  abdomen,  which, 
gradually  spreads  to  the  upper  abdomen.  The  intestinal  tract  is  usually  slug- 
gish (partial  intestinal  paralysis),  but  there  is  not  the  complete  absence  of 
bowel  movement,  such  as  is  seen  in  intestinal  obstruction. 

A  rise  of  temperature  within  the  first  twenty-four  hours  after  operation  is 
not  of  serious  significance.  Not  infrequently  in  extensive  operations,  involv- 
ing large  peritoneal  or  connective  tissue  surfaces,  there,  is  a  sharp  rise  of  tem- 
perature (up  to  102°  or  103°),  coming  on  within  twenty-four  hours  and  sub- 
siding the  second  or  third  day  without  further  disturbance.  In  the  absence 
of  a  more  definite,  explanation,  this  "aseptic  rise  of  temperature"  is  said 
to  be  due  to  the  "absorption  of  blood  ferment."  But  when  there  is  a  rising 
temperature  after  the  second  day,  it  is  indicative  of  some  unusual  dis- 
turbance, and  when  the  combination  of  symptoms  above  mentioned  is  present, 
the  diagnosis  of  peritonitis  is  clear. 

The  treatment  of  peritonitis  following  operation  is  the  same  as  for  peri- 
tonitis without  operation.  This  has  already  been  described  under  Acute  Pel- 
vie  Inflammation  (page  824). 

11.  Local  Suppuration.  This  is  indicated  by  fever,  coming  on  after  the 
sixth  day,  and  a  moderate  increase  in  the  pulse  rate  and  localized  pain.  If 
the  suppuration  is  deep  in  the  pelvis,  the  patient  complains  of  deep-seated 
pain  and  usually  of  backache  or  of  pain  extending  down  one  thigh.  If  the 
inflammatory  focus  is  situated  in  the  back  part  of  the  pelvis,  bowel  movement 
or  the  giving  of  an  enema  causes  pain.  Vaginal  examination  shows  a  boggy 
mass,  which  is  very  tender.  The  treatment  for  such  local  inflammation  deep 
in  the  pelvis  is  to  secure  good  bowel  movement,  to  make  the  patient  com- 
fortable, to  increase  tissue  resistance,  and  to  await  resolution  or  abscess  for- 
mation. When  fluctuation  can  be  detected  by  vaginal  examination,  open 
and  drain  the  abscess  per  vaginam.  Exceptionally,  it  may  be  advisable  to 
open  into  a  solid  mass  (inflammatory  focus  without  fluctuation)  or  to  open 
into  the  cul-de-sac  for  general  pelvic  drainage. 

"When  the  suppuration  is  in  the  abdominal  incision,  there  is  increasing 
pain  along  the  course  of  the  incision.  This  calls  for  removal  of  the  dressing 
and  inspection  of  the  wound.  Inflammation  at  this  point,  is  indicated  by  the  cardi- 
nal signs  (pain,  heat,  redness  and  swelling),  localized  at  some  part  of  the  incision, 
or  extending  all  along  it.  If  the  disturbance  is  slight,  a  hot  moist  anti- 
septic dressing,  changed  every  twenty-four  hours,  may  be  sufficient.  If  there 
is  a  pronounced  cellulitis  at  some  point,  that  portion  of  the  wound  should 
be  opened  superficially  and  a  gauze  or  tube  drain  put  in  and  the  hot  moist 
dressing  applied.  If  drainage  of  the  infected  area  can  be  satisfactorily 
effected  without  removing  the  tension  sutures,  that  is  preferable.  In  some 
instances  the  inflammation  is  confined  to  the  subcutaneous  tissue  and  no  dis- 
turbance of  the  deep  buried  sutures  is  necessary.  The  important  point,  how- 
ever, is  to  secure  free  drainage  of  the  infected  area  and  prevent  serious 
absorption.    If  the  whole  wound  is  infected,  it  must  all  be  drained.    In  such  a 


1102  AFTER-TREATMENT  IN   OPERATIVE    CASES 

case,  the  whole  wound  (except  the  peritoneum)  is  likely  to  open.  As  soon  as 
serious  absorption  has  ceased,  the  sides  of  the  wound  are  brought  together 
by  strapping  with  adhesive  strips,  the  wound  being  exposed  and  cleansed 
every  day  or  two  (depending  on  the  amount  of  discharge)  with  hydrogen 
peroxide.  Later,  if  thought  perferable,  the  granulating  surfaces  may  be 
freshened  by  curetting  and  then  brought  together  by  sutures,  with  the  idea  of 
securing  secondary  union. 

12.  Phlebitis.  This  seldom  occurs  now,  since  patients  are  got  out  of 
bed  earlier.  When  it  does  appear,  it  is  usually  in  about  the  third  week,  when  the 
patient  has  passed  the  time  for  the  ordinary  operative  complications  and  is 
congratulating  herself  that  she  will  soon  be  entirely  well. 

She  complains  of  pain  in  the  groin  and  upper  part  of  the  thigh  on  one 
side,  and  the  temperature  gradually  rises  to  102°  or  103°.  There  may  or  may 
not  be  swelling  of  the  foot  and  leg,  but  there  is  always  tenderness  on 
pressure  over  the  femoral  vessels  just  below  Poupart's  ligament.  This  ten- 
derness may,  in  some  cases,  be  traced  a  considerable  distance  down  the  thigh, 
and  also  up  along  the  iliac  vessels. 

The  treatment  of  phlebitis  is  immediate  bandaging  of  the  leg  and  thigh 
(from  toes  up),  elevation  of  the  leg  in  a  comfortable  position  on  pillows, 
and  the  maintenance  of  this  position  and  of  the  dorsal  posture  for  several 
days.  In  mild  cases  the  measures  mentioned  usually  relieve  the  spontaneous 
pain,  but  in  the  severe  cases  sedatives  may  be  necessary  for  a  time  to  give  rest. 
It  will  be  necessary  to  maintain  this  position  most  of  the  time  for  a  Aveek 
or  more,  depending  on  the  severity  of  the  trouble  and  the  rapidity  of  the 
improvement.  When  the  above  treatment  is  carried  out  promptly  and  persist- 
ently, serious  trouble  seldom  results.  If  the  patient  is  permitted  to  use  the 
leg,  the  suffering  is  increased  and  the  disability  prolonged,  and  there  is  dan- 
ger of  serious  embolism  by  particles  detached  from  the  thrombosed  area  in 
the  vein  and  carried  to  the  brain  or  heart  or  lungs.  On  account  of  the  danger 
of  detaching  emboli,  no  massage  or  rubbing  of  the  involved  area  is  permis- 
sible until  sometime  after  all  acute  symptoms  have  subsided. 

Getting  patients  out  of  bed  early  (at  the  end  of  a  week)  has  almost  elimi- 
nated this  complication  also  in  the  authors  personal  experience.  Under  the 
old  regimen  of  keeping  the  patients  in  bed  three  weeks  it  was  rather  fre- 
quent, occurring  in  about  two  per  cent  of  the  abdominal  operative  cases. 

13.  Pain  During  Convalescence.  Aside  from  the  conditions  already  men- 
tioned and  the  natural  soreness  of  the  recently  disturbed  structures,  pain 
during  convalescence  is  usually  due  to  gastric  or  intestinal  indigestion,  with 
gas  formation  and  resulting  painful  intestinal  peristalsis.  The  treatment 
for  this  condition  is  to  remove  the  irritating  material  from  the  intestinal 
tract  by  an  enema  and  laxatives,  and,  if  necessary,  administer  some  remedy 
for  the  gastric  or  intestinal  indigestion.  Of  course,  operated  patients  are 
subject  to  neuralgic  and  neurasthenic  pains  the  same  as  other  individuals, 
and  these  are  likely  to  be  more  pronounced  at  the  menstrual  time. 


AFTER-TREATMENT  IN  VAGINAL   OPERATIONS  1103 

An  abdominal  operation  often  causes  the  menstrual  flow  to  appear  ahead 
of  time.  Not  infrequently  there  is  also  a  slight  bloody  flow  from  the  uterus, 
without  any  relation  to  menstruation,  within  a  few  days  after  the  operation. 
Such  need  occasion  no  alarm,  as  it  disappears  in  a  short  time. 

14.  Subsequent  Disturbances.  As  the  patient  begins  to  walk  about,  there 
may  be  more  or  less  soreness  in  the  pelvis  for  some  time,  until  the  hyperemia 
of  the  healing  tissues  has  disappeared  and  the  new  connective  tissue  is  firm. 

In  drainage  cases  a  sinus  sometimes  persists.  The  persistence  of  such  a 
sinus  may  be  due  to  sloughing  tissue  or  to  a  ligature.  In  the  case  of  a  cat- 
gut ligature  or  sloughing  tissue,  the  troublesome  material  will  usually  dis- 
integrate and  come  away  in  the  course  of  some  weeks.  The  sinus-track,  in 
the  mean  time,  should  be  kept  clean  by  frequent  cleansing  with  hydrogen 
peroxide — every  day  or  two,  depending  on  the  amount  of  discharge.  The 
patient  can  care  for  the  fistula  at  home  after  being  shown  how  to  apply  the 
peroxide  and  the  dressing. 

If  a  silk  ligature  is  at  the  bottom  of  the  sinus,  it  may  come  out  itself  after 
some  weeks  or  months,  or  it  may  have  to  be  taken  out.  Sometimes  it  may 
be  caught  up  by  "fishing"  with  a  silkworm-gut  or  other  contrivance.  Other- 
wise, it  must  "be  removed  by  operation.  A  rare  cause  of  persistent  fistula 
is  a  sponge  or  forceps  left  in  the  cavity. 

Occasionally  a  fistula  connected  Avith  the  bowel  follows  abdominal  sec- 
tion. Ordinarily  such  a  fistula  should  be  treated  by  a  simple  cleansing  for 
some  time,  for  in  a  considerable  portion  of  the  cases  it  will  heal  spontaneously 
within  a  few  weeks.  If  it  persists  indefinitely,  it  requires  operative  treatment. 
Such  an  operation  should  not  be  undertaken  lightly,  for  it  may  prove  very  diffi- 
cult and  dangerous. 

A  hernia  in  the  scar  indicates  defective  healing  of  the  wound.  This  is 
usually  due  to  the  necessity  for  drainage,  which  prevents  perfect  approxima- 
tion of  the  sides  of  the  wound.  If  the  hernia  is  small,  it  may  in  some  cases 
be  held  back  satisfactorily  by  an  abdominal  supporter.  If  large,  or  if  per- 
sistently troublesome  even  though  small,  it  requires  operative  treatment. 

AFTER-TREATMENT  IN  VAGINAL  OPERATIONS 

The  general  after-treatment  of  vaginal  operations  is  practically  the  same 
as  for  abdominal  operations. 

Gauze  extending  from  the  vagina  into  the  peritoneal  cavity  is  removed 
usually  in  three  or  four  days.  After  removing  gauze,  if  there  is  much  of  a 
cavity,  it  is  advisable  to  replace  the  gauze  in  the  vaginal  incision,  to  keep  it 
open  until  the  cavity  is  nearly  closed  by  granulation.  In  the  case  of  an 
abscess  cavity,  a  rubber  tube,  arranged  as  previously  explained  (Fig  670),  is 
preferable.    After  the  gauze  is  left  out  of  the  vagina,  a  cleansing  douche  of 


1104 


AFTER-TREATMENT    IN    OPERATIVE    CASES 


iiormal  saline  solution  or  an  antiseptic  solution  is  given  once  or  twice  daily, 
depending  on  the  amount  of  discharge. 

After  a  vaginal  or  perineal  operation  the  vulva  and  adjacent  surfaces  must 
be  kept  covered  with  an  antiseptic  dressing,  the  same  as  any  other  wound 
region.  Here,  however,  on  account  of  the  necessity  of  evacuation  of  the  bowel 
and  bladder,  the  problem  of  wound  protection  is  more  complicated.  The 
dressing  must  be  changed  several  times  daily  and  with  each  change  of 
dressing  there  is  danger  of  contamination. 

When  it  is  necessary  to  change  the  dressing,  the  nurse  should  disinfect 


Fig.   797.      Cleansing  the   External   Genitals.      The   use   of  the   "Pitcher  douche." 


her  hands  and  then  cleanse  the  operative  field  with  an  antiseptic  solution 
(e.g.,  bichloride  1-5000).  The  cleansing  may  be  conveniently  accomplished 
by  means  of  the  "pitcher  douche"  (Fig.  797).  After  the  cleansing,  a  fresh 
'dressing  is  put  on  and  the  T-bandage  again  applied  (Fig.  798). 

If  the  patient  can  pass  the  urine,  she  should  ordinarily  be  permitted  to  do 
so,  whatever  the  character  of  the  vaginal  work.  Catheterization  is  more  likely 
to  do  harm  than  urination,  especially  as  the  urine  remaining  on  the  genitals 
is  at  once  removed  by  the  cleansing  solution.  To  aid  spontaneous  urina- 
tion, patient  may  be  propped  up,  hot  packs  on  the  vulva  may  be  used,  and  also 
firm  pressure   over  the  bladder  as  the  patient  is  trying  to  urinate.      Hot 


AFTER-TREATMEXT   IN   VAGINAL    OPERATIONS 


1105 


douches  also  aid  some,  and  may  be  used  if  there  is  no  contraindication.  In 
some  instances  pituitriu,  given  hypodermatically,  will  successfully  overcome 
the  retention. 

In  many  cases,  however,  the  patient  can  not  urinate  at  first,  and  must  be 
catheterized  for  two  or  three,  or  more,  days.  Catheterization  must  be  carried 
out  under  strict  antiseptic  precautions.  The  catheter  is  boiled,  the  nurse's 
hands  are  disinfected,  and  the  vestibule  and  meatus  of  the  patient  are  care- 


Fig.   798.     The   Vulvar   Dressing  Applied.      This   dressing  should   be  large   enough   to   cover   all   the   adjacent 
surfaces,    including   the   pubic   hairy    region,    and   should   be   kept   spread    out   by   a   wide    T-bandage. 


fully  cleansed  with  an  antiseptic  solution.  After  the  labia  are  once  separated 
and  the  vestibule  cleansed,  the  labia  must  be  kept  separated,  so  that  there 
is  no  recontamination  of  the  vicinity  of  the  meatus,  until  the  catheter  is 
introduced  fFigs.  799,  800).  Care  should  be  taken  to  avoid  touching  the  part 
of  the  catheter  which  enters  the  bladder.  The  catheter  should  be  grasped 
well  back  from  the  point,  as  shown  in  Fig.  800.  In  order  to  prevent  cystitis, 
it  is  well  to  give  the  patient  some  reliable  internal  urinary  antiseptic  while 
she  has  to  be  catheterized  and  for  several  days  after  the  urine  is  passed 


1106 


AFTER-TREATMENT   IN   OPERATIVE    CASES 


Fig.  799.  Catheterization.  After  the  nurse  cleanses  the  vestibule  as  here  indicated,  the  labia  must 
be  kept  spread  apart  until  the  catheter  is  introduced.  When  the  labia  are  allowed  to  drop  back  over  the 
meatus  after  cleansing,  the  meatus  must  be  again  cleansed  with  the  antiseptic  solution  before  the  catheter 
is  introduced. 


Fig.  800.  Catheterization.  After  the  catheter  is  boiled,  do  not  touch  the  point  with  the  fingers.  The 
catheter  is  grasped  well  back  from  the  point,  as  here  shown,  and  the  point  is  introduced  into  the  urethra 
without  touching  the  labia  or  the  fingers.  A  glass  catheter  or  a  soft  rubber  catheter  may  be  used,  as  pre- 
ferred. 


AFTER-TREATMENT   IN   VAGINAL   OPERATIONS  1107 

spontaneously.  An  additional  precaution  is  to  have  the  bladder  irrigated 
with  3  per  cent  boric  acid  solution  once  or  twice  daily  while  catheterization  is 
necessary. 

For  the  After-treatment  of  Pelvic  Abscess,  see  page  820. 
For  the  After-treatment  of  Perineorrhaphy,  see  page  555. 
For  the  After-treatment  of  Trachelorrhaphy,  see  page  619. 
For  the  After-treatment  of  Curetment,  see  page  655. 

The  After-treatment  of  Extraperitoneal  Shortening  of  Round  Ligaments  is 

practically  the  same  as  for  Abdominal  Section  with  the  special  points  for 
Retrodisplacement  cases,  except  that  there  are  two  wounds  and  they  are 
situated  laterally  and  do  not  require  particular  support  after  they  are  healed. 


CHAPTER  XVIII 

MEDICO-LEGAL  POINTS  IN  GYNECOLOGY 

There  are  various  conditions  connected  with  the  genital  organs  concerning 
which  the  physician  may  be  called  to  testify  in  court  or  to  give  a  written 
opinion. 

Such  testimony  is,  generally  speaking,  simply  the  recitation  of  facts  in 
anatomy,  physiology,  pathology,  symptomatology,  diagnosis,  treatment  and 
prognosis,  with  which  the  physician  is  necessarily  more,  or  less  familiar  because 
of  his  daily  work.  But  there  are  certain  things,  of  little  or  no  value  in  the 
ordinary  diagnosis  and  treatment  of  diseases,  which  assume  much  importance 
when  the  case  comes  into  court.  So,  when  called  to  attend  a  case  in  which 
there  is  any  probability  of  court  proceedings,  the  facts  that  are  of  medico- 
legal importance  should  be  given  considerable  attention. 

Some  of  these  facts  in  connection  with  certain  subjects  that  frequently 
find  their  way  into  court  shall  be  pointed  out  here. 

RAPE 

Eape  is  defined  as  ''the  unlawful  carnal  knowledge  of  a  woman  without 
her  consent,"  and  again,  more  in  detail,  as  "sexual  intercourse  with  a  woman 
effected  by  violence,  or  with  a  young  girl  by  abuse  of  her  ignorance. ' ' 

Medical  evidence  is  ordinarily  required  to  confirm  or  disprove  the  state- 
ment that  rape  has  taken  place.  False  accusations  of  rape  are  very  fre- 
quent. Taylor  states  that  for  one  real  rape  tried  in  the  courts  there  were, 
on  the  average,  twelve  pretended  cases.  Some  of  these  cases  of  false  accusa- 
tion are  founded  on  a  mistake,  as  may  happen  with  infants,  children  and  per- 
sons mentally  defective.  In  other  cases  the  accusations  are  made  willfully 
and  designedly  for  the  purpose  of  extortion  or  revenge,  or  from  another  ulterior 
motive.  In  some  instances  the  false  accusation  may  be  at  once  disproved  by 
medical  evidence,  though  it  has  happened  that  the  medical  man  has  been 
deceived  and  duped  by  designing  persons.  In  many  cases  in  adults  the 
medical  evidence  is  not  decisive,  and  the  truth  or  falsity  of  the  charge  must 
rest  almost  wholly  on  the  statement  of  the  prosecutrix  herself  along  witli 
the  corroborating  circumstances. 

The  question  for  the  physician  to  decide  as  far  as  possible,  from  his  exam- 
ination, is  whether  or  not  sexual  intercourse  took  place,  or  was  attempted, 
at    approximately    the    time    indicated.      Subsidiary    information    may    be 

1108 


EAPE  1109 

required ;  e.  g.,  as  to  whether  there  -were  evidences  of  violence  elsewhere  on  the 
body,  or  as  to  whether  intercourse  has  ever  taken  place  or  has  frequently 
taken  place,  or  as  to  whether  death  was  caused  by  the  injuries  inflicted,  or 
as  to  whether  disease  Avas  communicated  at  the  time,  and  if  so,  what  is  the 
nature  and  probable  outcome  of  such  disease.  On  all  such  points  the  physi- 
cian is  supposed  to  be  informed,  and  he  is  also  supposed  to  keep  such  record 
of  his  cases  as  will  enable  him  to  testify  with  certainty,  some  years  after- 
ward, concerning  his  findings  in  any  particular  case. 

For  the  consideration  of  the  medical  evidence  of  rape  it  is  convenient  to 
divide  the  cases  into  three  classes,  the  first  including  infants  and  children,  the 
second  including  young  unmarried  women  and  the  third  including  married 
women. 

There  are,  however,  certain  points  that  should  be  kept  in  mind  in  all  cases. 
When  called  to  examine  or  treat  a  person  on  whom  rape  is  alleged  to  have 
been  committed,  notice  and  record,  as  soon  as  you  can  conveniently,  the  fol- 
lowing points,  for  you  are  likely  to  be  questioned  in  court  concerning  them. 

1.  The  precise  time  at  which  you  were  summoned,  the  exact  hour  and  date 
of  the  examination  and  the  place  of  the  examination.  It  is  important  in  some 
cases  to  know  whether  or  not  the  female,  alleged  assaulted,  took  the  earliest 
opportunity  to  complain.  Also,  the  exact  time  elapsing  between  the  alleged 
assault  and  the  examination  has  an  important  bearing  on  the  signs  found. 
The  place  of  the  examination  at  a  certain  time  may  be  important  as  showing 
the  truth  or  falsity  of  some  statement  of  the  defense  or  prosecution  regarding 
the  movements  of  the  female  shortly  after  the  time  of  the  alleged  assault. 

2.  Marks  of  violence  about  the  genitals. 

3.  Marks  of  violence  on  the  body  elsewhere  or  on  the  clothing  of  the  com- 
plainant. 

4.  Presence  of  stains  of  spermatic  fluid  or  of  blood  on  the  clothing.  When 
the  character  of  the  stain  is  not  clear,  make  a  microscopic  examination  of  the 
contaminating  material. 

5.  The  existence  of  disease  probably  conveyed  in  the  alleged  assault  (gon- 
orrhea, syphilis,  chancroid). 

The  evidences  of  rape  will  vary  with  the  age  of  the  patient  and  other  cir- 
cumstances. 

It  may  be  stated  that,  to  establish  the  fact  of  rape,  it  is  not  necessary  to 
prove  penetration  into  the  vagina  by  the  male  organ.  It  has  been  decided 
that,  if  the  evidence  shows  penetration  of  the  vulva  or  to  the  vulvar  cleft, 
that  is  sufficient- — the  legal  establishment  of  the  crime  requiring  only  the  fact 
of  the  penetration,  the  degree  of  penetration  being  quite  immaterial.  Conse- 
quently, the  hymen  is  not  necessarily  ruptured,  even  in  cases  where  entrance 
of  the  male  organ  into  the  vagina  would  be  absolutely  impossible  without 
such  rupture.  '^  Medical  men  sometimes  have  fallen  into  error  on  this  point, 
considering  that,  when  the  hymen  was  entire,  rape  could  not  have  been  com- 
mitted, but  the  statute  law  says  nothing  about  the  rupture  of  the  hymen  as  a 


1110  MEDICO-LEGAL   POINTS   IN   GYNECOLOGY 

necessary  part  of  the  medical  evidence ;  it  requires  from  the  medical  witness 
merely  proof  of  vulvar  penetration — this  may  occur  and  the  hymen  remain" 
intact."*  However,  laws  differ,  and  in  any  case  it  would  be  well  to  look  up 
the  wording  and  interpretation  of  the  law  in  the  state  or  country  where  the 
alleged  assault  occurred. 

Infants  and  Children 

In  the  case  of  infants  and  children  there  are  usually  decided  evidences  of 
injury  about  the  genital  organs.  Of  course,  such  injury  does  not  necessarily 
exist,  but  when  it  does  not  exist  the  proof  of  rape  must  rest  largely  on  evi- 
dence other  thaii  medical.  Again,  where  there  are  evidences  of  injury  about 
the  genitals  in  a  child  alleged  to  have  been  assaulted,  it  does  not  necessarily 
follow  that  the  injuries  are  due  to  rape.  The  abnormal  appearance  may  be 
due  to  some  disease  or  to  some  accidental  injury,  or  to  some  injury  inflicted 
by  a  designing  person  with  the  object  of  deceiving  the  physician.  All  these 
things  must  be  kept  in  mind.  In  this,  as  in  other  situations,  the  physician's 
diagnosis  of  the  conditions  present  and  the  interpretation  of  the  meaning  of 
those  conditions  must  be  founded  on  incontrovertible  physical  evidence  that 
will  stand  attack  from  all  sides. 

The  evidences  of  rape  will,  of  course.,  vary  much  with  the  time  that  elapses 
after  the  occurrence  before  the  child  is  seen. 

1.  If  the  child  is  seen  within  a  few  hours,  the  following  conditions  may  be 
present : 

a.  More  or  less  abrasion  of  the  vulva  and  vaginal  opening,  with  probably 
some  bleeding  or  clots.  If  penetration  into  the  vagina  has  taken  place,  there 
may  be  extensive  injuries — tearing  of  the  hymen,  perineum,  and  vaginal  walls 
into  the  rectum  or  even  into  the  peritoneal  cavity  (Figs  219,  220). 

b.  Evidences  of  violence  elsewhere  on  the  body  or  about  the  clothing — 
scratches  or  bruises  on  the  body,  tears  of  clothing,  or  blood  on  same  or  disar- 
rangement of  same.  In  some  cases  the  child  has  been  rendered  insensible  by 
a  blow  on  the  head  or  by  some  drug  administered. 

c.  Presence  of  semen  in  the  vicinity  of  the  genitals  of  the  child  or  on  the 
clothing.  The  contaminating  material  should  be  submitted  to  microscopic 
examination,  that  the  presence  or  absence  of  spermatozoa  (as  a  positive  evi- 
dence of  semen)  may  be  determined. 

d.  Presence  of  gonorrheal  pus  on  the  genitals.  The  presence  of  pus  about 
the  genitals  of  the  child  does  not  necessarily  indicate  rape.  The  pus  may  have 
been  put  there,  with  blood  and  scratches,  for  purposes  of  deception.  If  micro- 
scopic examination  of  the  pus  shows  gonococci,  it  has  come,  directly  or 
indirectly,  from  gonorrheal  inflammation  in  a  male  or  female.  Gonorrheal 
ophthalmia  is  a  not  infrequent  form  of  gonorrheal  inflammation,  and  the  pus 

*Taylor's  Medical  Jurisprudence:     American  Edition  by  Clark  Bell. 


RAPE 


1111 


from  such  a  condition  in  the.  mother  or  attendant  may  be  responsible  for  the 
gonorrheal  vulvitis  in  the  child. 

2.  If  the  child  is  seen  after  a  few  days  or  a  week  or  so,  the  following  con- 
ditions may  be  found : 

a.  Acute  inflammation,  apparently  due  to  violence.  The  fact  that  inflam- 
mation is  present  is  established  by  the  presence  of  a  muco-purulent  discharge, 
yellowish  in  color  and  staining  the  linen.  This  may  not  be  present  the  first 
day  or  two,  but  after  that  it  is  ordinarily  present  if  there  has  been  much 
injury  of  the  vulva  or  vagina.  The  inflammation  is  further  indicated  by  the 
redness  of  the  parts,  the  tenderness  and  the  pain  on  urination. 

The  acuteness  or  recent  onset  of  the  inflammation  is  shown  by  the  severity 
of  the  process  compared  with  its  extent,  the  marked  painfulness  of  the  affected 
areas,  the  presence  of  recent  abrasions  and  tears  about  the  hymen  and  vulva, 
and  possibly  swelling  from  edema.  The  parts  may  be  so  painful  that  the  child 
strongly  resists  any  attempt  to  make  an  examination — even  the  separation  of 
the  thighs.  This  is  of  no  diagnostic  significance,  as  children  with  inflammation 
from  other  causes,  or  even  with  no  inflammation,  may  do  the  same.  If  this 
obstacle  to  examination  is  extreme,  it  may  be  necessary  to  anesthetize  the 
child  in  order  to  make  the  examination.  If  extensive  inflammation  is  present, 
there  may  be  fever,  and  in  the  very  extreme  injuries  the  most  serious  acute 
symptoms  may  develop.  Several  deaths  from  this  cause,  with  consequent  con- 
victions for  murder,  have  been  recorded. 

The  fact  that  the  inflammation  was  immediately  preceded  by  violence  or 
mechanical  injury  is  shown  by  the  evidences  of  recent  tears  or  abrasions,  or 
by  ecchymoses  due  to  bruises  from  some  cause,  and  also  by  the  extent  and 
severity  of  the  inflammation  in  such  a  short  time  and  without  other  apparent 
cause.  Gangrene  with  sloughing  of  the  external  genitals  and  vagina  and  adja- 
cent tissues  has  occurred  from  these  causes,  usually  with  fatal  effect,  though 
some  have  recovered  after  considerable  sloughing. 

Care  should  be  taken  to  exclude  similarly  appearing  conditions  due  to 
other  causes.  The  very  severe  inflammation  of  the  genitals  called  ''noma"  has 
more  than  once  led  to  a  mistaken  supposition  of  rape.  It  is  seen  principally 
in  debilitated  children  with  severe  acute  diseases,  such  as  scarlet  fever,  diph- 
theria, typhoid  fever,  etc.  Occasionally,  however,  it  occurs  in  apparently 
healthy  children  where  the  genitals  are  neglected  and  dirty,  permitting  some 
severe  infection.  It  may  follow  marked  bruising  or  injuries  of  the  parts  from 
any  cause.  It  may  follow  even  a  comparatively  slight  injury  in  an  otherwise 
healthy  child.  Taylor  relates  a  rapidly  fatal  case  in  a  child  5  years  old  who 
accidentally  fell  on  some  thorns,  from  which  she  sustained  slight  injuries,  fol- 
lowed by  a  severe  infection  and  noma  and  death.  The  condition  of  the  parts, 
with  the  evidence  of  mechanical  injury,  were  such  that  it  might  easily  have 
led  to  a  charge  of  rape,  had  the  real  cause  not  been  known. 

b.  Gonorrheal  inflammation  in  the  acute  state.  Gonorrheal  inflammation 
is  likely  to  extend  into  the  urethra,  though  the  vagina  may  escape.    The  diag- 


1112  MEDICO-LEGAL   POINTS   IN   GYNECOLOGY 

nosis  of  gonorrheal  inflammation  is  established  by  finding  gonococci  in  the 
discharge.  The  signifiance  of  the  presence-  of  acute  gonorrheal  inflamma- 
tion depends  on  circumstances  as  already  explained. 

c.  Evidences  of  chancroidal  infection  (page  472). 

d.  There  may  be  present  some  of  the  other  conditions  mentioned  under 
the  earlier  examination. 

The  disturbance  of  the  parts  may  be  very  slight,  as  shown  in  cases  where 
other  circumstances  proved  the  rape.  For  example,  an  adult  was  convicted 
of  rape  on  an  infant  only  seven  months  old.  According  to  the  medical  evi- 
dence the  vulva  was  somewhat  swollen,  there  was  slight  excoriation  about 
the  labia  minora  and  a  small  amount  of  blood.  The  hymen  was  not  lacerated, 
and  there  was  no  evidence  of  penetration  past  it.  Seminal  fluid  was  found  on 
the  person  of  the  child. 

The  evidences  of  rape,  when  not  severe,  may  very  quickly  disappear. 
Casper  relates  a  case  of  a  girl  of  8  years  upon  whom  rape  was  committed  by  a 
man  in  a  drunken  condition.  The  girl  was  examined  the  next  day.  The  labia 
were  then  reddened,  and  there  was  congestion  about  the  vaginal  entrance, 
which  was  very  tender.  Examination  ten  days  later  showed  the  genitals  to  be 
in  their  natural  state,  and  there  was  nothing  at  that  time  to  indicate  that  the 
girl  had  been  subjected  to  violence. 

3.  An  examination  after  some  weeks  or  months  may  show  no  evidence  of 
the  disturbance,  or  may  show  one  or  more  of  the  following  conditions : 

a.  Chronic  muco-purulent  discharge  from  the  vulva  or  vagina.  This  is 
present  in  many  infants  and  young  girls  from  simple  causes,  such  as  want  of 
cleanliness,  scalding  from  frequent  irritating  bowel  movements,  seat  worms, 
irritating  urine,  adherent  prepuce  over  clitoris,  skin  diseases  of  the  vulva, 
pediculi  and  various  other  sources  of  irritation  about  the  genitals. 

b.  Chronic  gonorrheal  discharge  from  the  external  genitals  or  vagina. 
The  fact  that  the  discharge  is  gonorrheal  is  established  by  finding  gonococci. 
If  the  beginning  of  this  discharge  can  be  fixed  as  about  the  time  of  the 
alleged  assault,  it  is  strong  corroborative  proof.  Gonorrheal  vulvitis  and 
vaginitis  occur,  however,  not  infrequently  from  wholly  different  causes,  as 
previously  stated. 

c.  Evidences  of  syphilis  or  chancroid. 

d.  Laceration  or  destruction  of  hymen.  The  presence  of  the  intact  hymen 
does  not  preclude  rape,  as  previously  explained,  neither  does  the  absence  of 
the  hymen  or  apparent  laceration  of  the  hymen  necessarily  imply  injury  of 
the  membrane  by  rape  or  otherwise,  though  the  condition  of  the  hymen  might 
be  strong  corroborative  proof  in  a  particular  case,  especially  if  it  could  be 
established  by  the  mother  or  the  nurse,  or  a  physician  who  had  made  an 
inspection,  that  there  was,  prior  to  the  time  of  the  alleged  assault,  a  well- 
formed  and  apparently  intact  hymen.  The  hymen  is  very  different  in  shape 
and  appearance  in  different  individuals  (Fig  193).  Occasionally  it  is  prac- 
tically absent  in  a  child  otherwise  normal. 


EAPE  1113 

e.  i\biiormal  size  of  vagina,  as  though  it  had  been  at  one  time  dilated. 
Permanent  marked  dilatation  is  not  very  likely  to  follow  a  single  distention 
by  coitus  or  otherwise.  This  condition,  which  is  found  occasionally  in  older 
girls  where  the  question  arises,  is  due  usually  to  repeated  distention  of  the 
vagina,  by  coitus  or  otherwise,  extending  over  a  considerable  period  of  time. 
In  such  cases,  the  parts  may  soften  and  relax  to  a  remarkable  extent,  even 
leading  to  the  suspicion  that  childbirth  may  have  taken  place. 

f.  Scars  from  injury  of  the  genitals.  The  genitals  are  exceptionally  well 
protected,  and  are  not  often  injured,  except  by  some  disease  process  or  in 
attempts  at  coitus.  Occasionally  a  child  will  fall  astride  of  some  object  and 
inflict  an  injury.  Again,  injury  may  come  from  attempts  of  the  child  to  intro- 
duce some  foreign  body  into  the  vagina,  though  such  injuries  are  more  likely 
to  be  found  in  girls  somewhat  older.  Scars  about  the  genitals  may,  of  course, 
result  from  any  severe  inflammation  or  destructive  process,  and  also  from 
chronic  inflammation  of  milder  grade  when  it  is  accompanied  by  persistent 
scratching,  with  resulting  ulceration. 

Older  Girls  and  Unmarried  Women 

In  this  class,  the  severity  and  certainty  of  the  signs  decrease  and  the  diffi- 
culties of  arriving  at  a  definite  conclusion  increase.  The  mechanical  injuries 
following  coitus,  or  attempted  coitus,  are  less  marked  and  sooner  disappear, 
and  there  remain  fewer  deviations  from  the  normal.  Again,  in  the  case  of 
older  girls  and  adult  women  the  medical  man  is  likely  to  be  subjected  to 
two  lines  of  questioning — (A)  as  to  whether  or  not  coitus  or  attempted  coitus 
took  place  at  about  the  time  of  the  alleged  assault,  and  (B)  whether  or  not 
coitus  has  ever  taken  place  before,  and,  if  so,  Avhether  several  times  or  over  a 
considerable  period. 

A.  Evidences  of  Recent  Coitus  or  Attempted  Coitus.  The  evidences  found 
Avill,  of  course,  depend  to  a  considerable  extent  on  the  period  of  time  which 
intervenes  between  the  assault  and  the  examination.  If  the  examination  is 
made  within  a  few  hours  after  the  assault,  one  or  more  of  the  conditions  men- 
tioned on  page  1110  may  be  found.  The  mechanical  injury  to  the  genitals  is 
likely  to  be  less  because  the  parts  are  larger,  and  the  epidermis  less  delicate 
and  less  easily  abraded.  The  evidences  of  injury  on  other  parts  of  the  body  are 
likely  to  be  more  marked  because  of  the  greater  resistance  Avhich  the  victim 
is  able  to  make. 

If  the  examiiiation  is  made  after  a  few  days  or  a  week,  the  additional 
points  mentioned  on  page  1111  must  be  investigated.  As  the  local  injuries  are 
less  than  in  younger  females,  they  will  subside  more  quickly. 

If  the  examination  is  made  after  several  weeks  or  months,  the  problem  for 
the  physician  resolves  itself  into  determining  whether  or  not  sexual  inter- 
course has  ever  taken  place.  The  determination  of  the  time  w^hen  the  coitus' 
took  place  is  ordinarily  impossible  after  several  weeks  have  elapsed.    In  eer- 


1114  MEDICO-LEGAL   POINTS   IN   GYNECOLOGY 

tain  cases  the  medical  testimony  may  be  strongly  corroborative  of  other  testi- 
mony in  establishing  the  time  of  the  assault,  even  after  several  months.  For 
example,  if  it  should  be  established  by  other  testimony  (a)  that  up  to  the 
time  of  the  assault  the  young  woman  was  perfectly  well  and  had  never  had 
coitus,  and  (b)  that  immediately  afterward  she  had  a  discharge  and  had  been 
sick  more  or  less  ever  since,  and  (c)  that  there  had  been  no  subsequent 
coitus — then  the  finding  of  a  chronic  pyosalpinx  with  chronic  endometritis, 
in  an  examination  some  months  later,  would  be  strong  corroborative  proof 
that  the  infecting  coitus  took  place  about  the  time  of  the  alleged  assault. 

Ordinarily,  however,  after  a  few  weeks  all  the  acute  and  subacute  evi- 
dences have  subsided,  leaving  only  those  that,  so  far  as  any  distinctive  char- 
acteristics are  concerned,  might  have  been  there  some  months  or  some  years. 
So  the  question  here  is  essentially  whether  or  not  coitus  has  ever  taken  place 
in  the  case  of  the  individual  concerned. 

B.  Evidences  of  Remote  Coitus.  Ordinarily,  it  is  easy  to  tell,  by  a  compara- 
tively superficial  examination,  whether  or  not  a  girl  or  woman  has  probably 
had  coitus.  The  differences  in  appearance  of  the  external  genitals  and  vagina 
when  coitus  has  taken  place  (especially  if  it  has  ta]?:en  place  several  times) 
are  usually  so  marked  that  the  physician  has  little  difficulty  in  distinguish- 
ing them.  This  is  the  general  rule.  There  are,  however,  exceptional  cases 
which  present  many  of  the  ordinary  evidences  of  coitus  when  in  fact  none 
has  taken  place.  On  the  other  hand,  there  are  persons  who  present  signs 
which  are  considered  almost  pathognomonic  of  virginity  when  in  fact  sexual 
intercourse  has  occurred,  and  not  only  sexual  intercourse,  but  pregnancy  and 
labor  at  full  term.  So,  in  exceptional  cases  it  may  be  very  difficult  to  decide 
certainly  whether  or  not  sexual  intercourse  has  occurred,  and  in  such  a  case 
it  is  particularly  difficult  to  legally  prove  the  same,  for  the  anomalies  must 
then  be  considered. 

The  Evidences  of  Remote  Coitus  or  attempted  coitus  can  be  summed  up  as 
follows: 

1.  Evidences  of  previous  childbirth  at  or  near  term. 

a.  Destruction  of  the  hymen,  leaving  only  irregular  tags  here  and  there 
about  the  vaginal  opening,  with  scar-tissue  between.  This  condition  is  very 
strong  evidence  of  childbirth  at  or  near  term.  It  means  that  there  has  passed 
through  the  vaginal  opening  some  body  large  enough  not  only  to  stretch 
and  lacerate  the  hymen,  but  to  stretch  out  the  vaginal  ring  enormously,  and 
to  so  stretch  and  compress  and  bruise  the  hymen  that  the  subsequent  slough- 
ing and  scar-contraction  has  practically  destroyed  it.  There  is  really  no 
hymen  that  can  be  traced  as  a  circular  ring  of  tissue  with  simply  laceration 
from  intercourse.  The  hymen,  as  such,  is  gone,  and  there  remain  only  irregular 
projecting  particles  of  tissue  (carunculae  myrtiformes)  here  and  there  to 
mark  the  place  where  the  hymen  used  to  be.  Of  course  a  large  tumor ;  e.  g.,  a 
fibroid — delivered  through  the  vagina  might  do  the  same.  Also,  some  destruc- 
tive inflammatory  process  or  serious  injury  during  childhood  or  later  might 


RAPE  1115 

produce  practically  the  same  result,  but  such  conditions  are  rare  and  show 
also  other  evidences.  There  are  eases  of  congenital  deformity  in  which  the 
hymen  may  be  present  simply  as  irregular  tags  of  tissue,  or  it  may,  as  recorded 
in  some  cases,  be  absent  altogether.  In  such  cases,  we  would  not  expect  the 
scar-tissue  about  the  vaginal  opening  nor  the  marked  enlargement  of  the 
opening.  So  the  destruction  of  the  hymen  as  described,  when  present,  is 
strong  presumptive  evidence  of  previous  childbirth. 

Suppose  the  hymen  is  not  destroyed — does  that  prove  that  no  childbirth 
has  taken  place?  Not  necessarily.  Occasionally  during  the  labor  the  hymen  is 
simply  torn  and  then  the  ring  beyond  it  is  stretched  and  torn.  After  labor,  the 
portions  may  heal  in  such  a  way  that  the  hymen  appears  practically  intact. 
Still  rarer  cases  have  been  recorded  in  which  the  hjTnen  softened  and  dilated 
sufficiently  to  permit  the  child  to  pass  and  then  underwent  involution  to 
about  its  former  size.  Such  a  hymen  is  likely  to  stretch  also  during  coitus 
instead  of  tearing.  The  examination  of  such  a  patient  would  show  an  "intact 
hymen,"  or,  as  some,  laying  too  much  stress  on  the  condition  of  the  hymen, 
are  wont  to  write,  ''virgo  intacta."  The  absurdity  of  such  a  designation  based 
only  on  the  condition  of  the  hymen  is  well  expressed  by  Taylor  when  he 
remarks,  ''Such  'virgines  intactae'  have  frequently  required  the  assistance  of 
accoucheurs  and  have  in  due  time  been  delivered  of  children." 

b.  Evidences  of  laceration  or  great  stretching  of  the  perieum,  vagina  and 
pelvic  floor.  These  evidences  are  a  large  vaginal  opening,  close  approach  of 
the  opening  to  the  anus  (partial  destruction  of  perineal  body),  scars  about 
the  opening  or  on  the  perineum,  lax  vaginal  walls  and  lax  pehde  floor.  These 
have  about  the  same  significance  as  the  destruction  of  the  hymen  above 
mentioned — that  is,  their  presence  is  strong  evidence  of  previous  childbirth, 
but  their  absence  is  not  of  much  legal  significance. 

e.  Laceration  of  the  cervix.  The  establishment  of  a  distinct  laceration  of 
the  cer\nx  is  very  strong  evidence  of  a  previous  parturition  or  operation  involv- 
ing di^dsion  of  the  cervical  wall.  There  are  conditions  that  simulate  a  slight 
laceration,  but  a  deep  laceration  would  hardly  be  simulated  by  anything  short 
of  some  congenital  deformity,  and  in  such  a  case  there  Avould  be  likely  to  be 
other  deformities.  Also,  there  would  be  no  scar-tissue,  such  as  is  ordinarily 
found  about  a  laceration  of  the  cervix. 

d.  Evidences  of  previous  lactation.  It  may  be  possible  to  press  some  fluid 
from  the  breasts,  or  the  breasts  may  show  the  enlarged  viens  and  the  white 
striae  (lineae  albicantes)  of  a  previous  distention. 

e.  Evidences  of  a  previous  distention  of  the  abdominal  wall.  There  may 
be  present  the  striae  (lineae  albicantes)  indicative  of  previous  stretching  of 
the  skin  from  distention  from  pregnancy  or  other  causes.  "When  other  causes 
(obesity,  tumor,  ascites)  can  be  eliminated  by  the  history,  such  striae  indi- 
cate previous  pregnancy.  Also,  marked  relaxation  of  the  abdominal  wall  may 
be  due  to  previous  distention  by  pregnancy. 

2.  Evidences  of  previous  abortion.    The  evidences  are  exceedingly  uncer- 


1116  MEDICO-LEGAL   POINTS   IN   GYNECOLOGY 

tain  in  many  cases  after  a  short  time.  There  may  be  some  slight  lacerations, 
with  resulting  scars,  that  may  be  corroborative  evidence,  especially  partial 
laceration  of  cervix.  Their  presence  may  help  some,  but  their  absence  is  of 
no  particular  significance. 

3.  Laceration  of  Hymen  and  some  dilatation  and  laxity  of  vaginal  opening 
and  vaginal  canal.  These  are  the  ordinary  evidences  of  coitus  and  are  nearly 
always  present,  especially  if  repeated  coitus  has  taken  place.  Usually  the 
opening  in  a  virgin  hymen  is  so  small  that  the  introduction  of  one  finger  is 
effected  with  some  difficulty  and  causes  pain.  Ordinarily,  after  repeated 
coitus  has  taken  ]3lace,  the  vaginal  opening  admits  two  fingers  easily  for 
examination,  and  without  pain,  providing  the  perineal  edge  of  the  opening 
is  carefully  depressed. 

In  exceptional  cases  the  hymen  may  remain  intact  after  coitus,  particularly 
in  those  cases  where  the  opening  is  large  and  a  little  stretching  will  accom- 
modate the  male  organ.  Occasionally,  however,  a  hymen  with  a  small  open- 
ing will  remain  intact.  In  such  cases  the  hymen  is  usually  elastic  and  un- 
usually tough,  and  consequently  it  stretches  and  dilates  under  a  force  that 
would  rupture  an  ordinary  hymen.  So  that,  though  it  may  be  said  that  there 
are  many  exceptions  to  the  rule  that  "coitus  ruptures  the  hymen,"  there  are 
very  few  cases  in  which  a  hymen  presenting  the  normal  rupture  capacity 
(of  normal  size,  normally  tense  and  having  the  normal  consistency,  elasticity, 
and  strength)  does  not  rupture  on  first  coitus.  In  doubtful  cases,  then,  the 
physician  should  take  care  to  ascertain  accurately,  not  only  the  presence  of 
the  hymen,  but  also  its  character. 

The  apparent  laceration  of  the  hymen  or  even  the  absence  of  the  hymen, 
while  presumptive  evidence  of  coitus,  is  not  positive  evidence  of  the  same. 
It  may  be  absent  wholly  or  partially  from  congenital  deformity.  It  may  have 
been  destroyed  or  dilated  by  disease  or  injury  in  infancy,  childhood  or  later 
life.  It  may  have  been  lacerated  by  an  operation  or  an  examination.  Its 
apparent  laceration  is,  however,  strong,  corroborative  evidence  of  coitus 
when  taken  in  connection  with  the  history  of  the  case,  and  especially  when 
there  is  reliable  testimony  establishing  that  it  was  formerly  intact. 

4.  Evidences  of  a  disease  usually  communicated  in  sexual  intercourse, 
such  as  gonorrhea,  syphilis,  chancroid,  pediculosis  pubis. 

5.  Evidences  of  uterine  or  tubal  inflammation,  presumably  due  to  infection 
following  labor  or  abortion,  or  coitus. 

Married  Women 

In  married  women  normal  sexual  intercourse  has,  of  course,  already  taken 
place,  so  that  the  establishment  of  the  fact  of  coitus  is  of  no  help  in  estab- 
lishing rape.  The  medical  evidence,  if  any  is  required,  must  bear  upon  the 
question  of  coitus  by  some  one  other  than  the  patient's  husband  and  against 
her  resistance. 


RAPE  1117 

The  following  points  should  be  investigated: 

1.  Evidences  of  injury  about  the  genitals,  indicative  of  forced  and  hurried 
coitus.     There  may  be  abrasions,  tears,  bruises  or  bleeding. 

2.  Evidences,  elsewhere  on  the  body  or  clothing,  of  injury  in  resistance. 
There  may  be  bruises  and  scratches,  or  an  excited  or  hysterical  state,  such  as 
might  be  caused  by  a  harrowing  experience.  The  clothing  may  show  tears  or 
bloodstains,  or  contamination  with  dirt  of  the  road  or  disarrangement.  Of 
course  none  of  these  evidences  of  violence  establish  the  crime  of  rape.  They 
only  go  to  show  that  something  was  attempted  that  excited  the  woman's  resistance. 
They  might  have  been  due  to  attempted  robbery  or  to  a  quarrel.  Again,  they 
may  have  been  placed  there  intentionally.  The  woman  may  be  trying  to 
deceive  for  the  purpose  of  extorting  money  or  for  other  reasons. 

,  3.  Stains  of  spermatic  fluid  may  be  present  on  the  clothing  or  person  of 
the  woman.  If  there  is  any  suspicious  stain,  some  of  the  contaminating  ma- 
terial should  be  submitted  to  microscopic  examination,  that  the  presence  or 
absence  of  spermatozoa  may  be  determined.  Any  discharge  in  the  vagina  may 
also  be  examined  microscopically,  but  the  presence  of  spermatozoa  in  the 
vaginal  discharge  is  not  of  much  significance  unless  it  can  be  established  that 
no  coitus  with  the  husband  has  taken  place  for  three  or  four  days. 

4.  Disease  (gonorrhea,  syphilis,  chancroid)  not  present  in  the  husband. 

The  Question  of  Consent 

The  question  of  consent  is  often  the  crucial  point  on  the  legal  side  of  these 
cases  of  alleged  rape  in  adult  women,  whether  married  or  unmarried.  This 
question  is,  as  a  rule,  decided  largely  or  wholly  by  testimony  other  than 
medical.  In  some  cases,  however,  the  medical  man  may  be  required  to  give 
testimony  concerning  corroborative  facts.  An  adult  woman  of  ordinary  health 
and  strength  is  supposed  to  make  strong  resistance.  In  such  a  case,  if  there 
are  no  obvious  evidences  of  resistance,  the  legal  assumption  is  that  consent 
was  given  and  the  case  is  not  one  of  rape.  It  has  been  claimed  that  a  strong 
woman  can  make  effective  resistance,  and  therefore  that  an  accusation  of  rape 
by  such  a  woman  is  an  absurdity.  ''Some  medical  jurists  have  argued  that  a 
rape  can  not  be  perpetrated  on  an  adult  woman  of  good  health  and  vigor,  and 
they  have  treated  all  accusations  made  under  these  circumstances  as  false." 
This  view  is  too  extreme,  for  there  are  circumstances  and  conditions  that 
would  make  effective  resistance  impossible  even  by  a  woman  of  unusual 
strength,  as  when  two  or  more  are  combined  in  the  attack  or  when  the  woman 
is  rendered  powerless  by  terror  or  by  exhaustion  from  long  struggling  with 
her  assailant.  The  physician  may  be  required  to  state  his  opinion  regarding 
the  possibility  or  probability  that  sexual  intercourse  could  take  place  without 
the  consent  of  the  woman  under  various  circumstances;  for  example,  the 
following : 


1118  MEDICO-LEGAL  POINTS  IN   GYNECOLOGY 

1.  When  a  woman  is  weak  from  age,  sickness  or  other  bodily  infirmity. 
That  coitus  could  be  forced  under  such  circumstances  is  evident. 

2.  Where  there  is  imbecility  or  other  form  of  mental  irresponsibility.  In 
such  a  case  consent  in  the  legal  sense  is  impossible. 

3.  When  the  woman  is  attacked  by  several  persons  or  by  one  person  of 
superior  strength.    Rape  is  unquestionably  possible  under  such  circumstances. 

4.  Where  there  is  unconsciousness  or  partial  unconsciousness  from  nar- 
cotics or  intoxicating  liquors.  Coitus  may  take  place  under  such  circum- 
stances without  the  consent,  and  in  some  cases  even  without  the  knowledge 
of  the  woman.  Many  young  women  are  ruined  in  this  way  in  the  ''wine- 
rooms"  of  our  cities.  This  fact  is  recognized  in  the  law  which  makes  it  a  crime 
to  give  a  woman  intoxicants  with  the  intention  of  stupefying  her,  so  that 
coitus  may  take  place  without  her  consent. 

5.  When  there  is  unconsciousness  or  partial  unconsciousness  from  a  gen- 
eral anesthetic,  such  as  chloroform  or  ether  or  laughing  gas.  The  fact  that 
rape  may,  and  occasionally  has  been,  committed  under  these  circumstances 
is  sometimes  taken  advantage  of  by  designing  persons  to  extort  blackmail 
from  dentists  and  others  who  must,  in  their  work,  anesthetize  or  partially 
anesthetize  patients  without  a  third  party  present. 

Anesthesia  or  partial  anesthesia  of  a  girl  or  woman  without  a  third  party 
present  is  hazardous  for  another  reason.  The  patient,  while  going  under  the 
anesthetic  or  recovering  from  the  same,  may  experience  certain  feelings  or 
hallucinations  that  cause  her  to  really  believe  and  firmly  proclaim  that  sexual 
intercourse  took  place.  Many  such  cases  of  false  accusations,  honestly  made, 
are  on  record.  In  one  instance  "a  young  lady  was  accompanied  to  a  dentist 
by  her  affianced  lover,  who  never  left  her  while  the  anesthetic  was  adminis- 
tered and  a  tooth  extracted ;  yet  she  could  scarcely  be  convinced  subsequently 
that  the  dentist  had  not  attempted  to  ravish  her. ' ' 

6.  When  there  is  unconsciousness  or  partial  unconsciousness  from  hypnotic 
sleep.  Convictions  have  occurred  of  undoubted  rape  under  this  condition. 
Also,  false  accusations  may  be  honestly  made  from  sensations  experienced  in 
this  condition.  This  comes  under  partial  or  complete  anesthesia.  Another 
source  of  false  accusations,  honestly  made,  is  mental  aberration  of  various 
kinds — from  well-marked  insanity  to  the  various  functional  nervous  dis- 
turbances. 

7.  When  there  is  unconsciousness  or  partial  unconsciousness  from  faint- 
ing, syncope,  an  epileptic  seizure,  a  fall  or  a  blow. 

8.  When  the  woman  is  temporarily  helpless  from  terror  or  from  an  over- 
powering feeling  of  horror  at  her  situation. 

9.  A  woman  may  cease  her  resistance  under  threats  of  death  or  duress. 

FOREIGN  BODIES  LEFT  IN  ABDOMEN 

This  is  a  subject  the  importance  of  which  is  frequently  not  appreciated  by 
the  physician  until  he  is  involved  in  a  lawsuit  concerning  the  same.     Conse- 


FOREIGN"  BODIES  LEFT  IN  ABDOMEN  1119 

quently  it  might  be  advantageous  to  call  attention  to  the  subject  by  detailing 
some  illustrative  eases,  that  the  danger  may  be  recognized  and  avoided. 

Lawsuit.  Small  Gauze  Strip  Extracted  from  Al)dominal  Sinus.  In  a  case  of  retro- 
flexion, Wiggin  did  a  vaginal  fixation  and  also  removed  the  left  ovary.  Suppuration  fol- 
lowed presumably  from  tlie  stump.  Later,  laparotomy  was  performed  for  tlie  removal  of 
the  ligatures.  This  was  followed  by  an  abscess  in  the  abdominal  wall  and  a  persistent 
sinus.  The  patient  then  went  to  another  institution,  and  later  a  small  gauze  strip  was 
taken  from  the  sinus.     Suit  was  entered  for  $10,000. 

Wiggin  contended  that  the  gauze  was  not  of  the  kind  he  used  in  sponging,  and  that 
the  small  strip  had  probably  been  left  in  the  sinus  while  the  patient  was  being  dressed  at 
the  other  institution.     Verdict  for  the  defendant. 

Lawsuit.  Small  Gauze  Sponge  Removed  by  Secondary  Operation.  The  patient  was 
operated  on  for  appendicitis  by  Gillette.  After  the  abdomen  was  open  it  was  found  that 
the  trouble  was  tubal  pregnancy.  The  appendix  incision  was  closed  and  a  median  inci- 
sion made,  and  through  that  the  operation  was  completed.  About  four  days  after  the 
operation,  the  appendix  incision  began  to  discharge  pus.  Gillette  treated  this  sinus 
persistently,  under  the  impression  that  it  was  kept  up  by  unabsorbed  kangaroo  tendon, 
which  m:ght  at  any  time  be  wholly  absorbed  and  thus  permit  healing.  After  twelve 
months  of  this  treatment  the  patient  went  to  another  physician,  who,  eighteen  months 
after  the  first  operation,  did  a  secondary  operation  and  found  a  small  gauze  sponge,  after 
which  the  patient  recovered.     Suit  was  entered  for  $5,000. 

In  the  trial  court  the  verdict  was  for  the  defendant  on  the  ground  that  the  cause 
of  action,  if  any  arose,  was  barred  by  the  statute  of  limitation.  The  Circuit  Court  held 
that  the  trial  court  was  in  error  and  reversed  the  decision.  The  Supreme  Court  was 
divided  equally  on  the  subject,  hence  the  decision  of  the  Circuit  Court  was  allowed  to 
stand — verdict  for  the  plaintiff. 

Lawsuit.  Sponge  Left  in  Abdomen.  Baldwin  was  made  defendant  in  a  suit,  and  a 
question  that  assumed  much  importance  in  the  case  was>  as  to  whether  the  responsibility 
for  the  count  of  the  sponges  lay  with  the  surgeon  or  with  the  nurse. 

The  suit  against  the  surgeon  was  finally  withdrawn,  and  legal  action  was  begun 
against  the  hospital  where  the  operation  occurred. 

Lawsuit.  Sponge  Removed  at  Secondary  Operation.  The  patient  was  operated  on 
for  an  abdominal  tumor  by  Thorne.  Several  months  later  a  secondary  operation  was  per- 
formed by  another  surgeon  and  a  sponge  was  found  in  the  abdominal  cavity.  The 
patient  recovered.  Legal  proceedings  were  begun  against  the  first  operator  (Miss  May 
Thorne)  on  the  ground  that  she  was  guilty  of  negligence  in  not  personally  counting 
the  sponges  used  in  the  course  of  the  operation  before  the  wound  was  closed. 

The  defendant  denied  negligence  and  held  that  the  leaving  of  a  sponge  was  an  acci- 
dent that  could  not  always  be  avoided.  She  further  said  that,  like  a  large  number  of 
other  operating  surgeons,  she  left  the  counting  of  the  sponges  to  a  responsible  nurse — 
considering  that  it  was  the  duty  of  the  surgeon  to  keep  his  or  her  eyes  continually 
upon  the  patient  until  the  wound  had  been  closed. 

The  judge,  in  summing  up  the  case,  said  there  was  no  doubt  that  the  defendant 
was  a  skillful  surgeon,  but  the  question  in  this  case  was  not  as  to  her  skill,  but  whether 
she  had  been  guilty  of  want  of  reasonable  care.  The  points  for  the  jury  were:  (1) 
whether  the  defendant  was  guilty  of  want  of  reasonable  care  in  counting  or  superin- 
tending the  counting  of  the  sponges;  (2)  whether  the  nurse  was  employed  by  the  defend- 
ant and  under  her  control  during  the  operation;  (3)  whether  the  nurse  was  guilty  of 
negligence  in  counting  the  sponges;  and  (4)  whether  the  counting  of  the  sponges  was  a 
vital  part   of  the  operation  which  the   defendant  undertook  to   see  properly  performed. 

After  lengthy  consideration  the  jury  returned  a  verdict  for  the  plaintiff. 


1120  MEDICO-LEGAL   POINTS   IN    GYNECOLOGY 

Criminal  Trial.  Sponge  Pound  at  Autopsy.  The  patient  was  subjected  to  explora- 
tory laparotomy  by  d'Antona.  A  carcinoma  of  the  liver  was  found,  and  an  unfavorable 
prognosis  given.  The  patient  recovered  from  the  immediate  effects  of  the  operation, 
but  died  after  a  month.  At  the  autopsy  a  gauze  pad,  70  by  40  cm.,  was  found  and  also 
two  liters  of  pus.  The  physicians  who  made  the  postmortem  examination  gave  out  a  state- 
ment to  the  effect  that  the  death  was  due  to  the  presence  of  the  sponge  and  the  peri- 
tonitis and  secondary  pleuritis  resulting  therefrom.  The  public  prosecutor  then  had 
d'Antona  indicted  and  placed  on  trial  for  criminal  negligence. 

The  verdict  was  that  the  patient  Avould  have  died  from  the  other  causes  present. 
The  prosecutor  then  claimed  that  the  hospital  records  had  been  falsified,  hence  a  new 
trial  was  granted.  In  the  second  trial  ten  experts  were  called  and  they  all  testified 
that  there  was  sufficient  cause  for  death  outside  of  any  influence  which  the  sponge 
within  the  abdomen  might  have  had.  The  trial  was  then  discontinued  because  of  the 
absence  of  prosecuting  evidence. 

This  case  was  reported  by  Prof.  Pio  Foa,  who  stated  that,  if  the  autopsy  had  been 
conducted  by  competent  pathologists,  such  an  erroneous  report  would  not  have  been 
made,  and  the  unfortunate  trials  would  not  have   occurred. 

Lawsuit.  Sponge  Left  in  Abdomen.  The  patient  was  subjected  to  abdominal  section 
by  Schooler.  Later  developments  indicated  that  a  sponge,  sixteen  inches  square,  had 
been  left  in  the  abdomen.     Suit  was  entered  for  $1,500.     Verdict  for  the  plaintiff. 

Lawsuit.  Sponge  Left  in  Abdomen,  The  husband  of  the  plaintiff  was  operated  on 
for  appendicitis  by  Hageboeck.  It  was  charged  that  a  surgeon's  sponge  had  been  left 
in  the  abdomen  and  that  this  caused  an  abscess  which  resulted  in  death.  Suit  was 
entered  for  $50,000. 

In  two  trials  the  jury  disagreed.  It  was  reported  that  in  each  trial  the  jurors  stood 
11  to  1  in  favor  of  the  plaintiff.  The  case  was  to  come  up  for  a  third  trial  the  latter 
part  of  the  year. 

Criminal  Trial.  Forceps  round  in  Abdominal  Cavity  at  Autopsy.  A  patient  with 
a  large  fibroid  was  operated  on  by  Lassallette.  Death  occurred  a  few  hours  after  the 
operation.      Autopsy   disclosed  a  forceps  in  the   peritoneal   cavity. 

At  the  trial,  the  operator  was  condemned  to  two  months  in  prison  for  homicide 
through  negligence.     The  sentence  Avas  served. 

After  serving  the  sentence,  Lassallette  put  in  a  plea  that  the  patient 's  death  had 
not  been  caused  by  the  retention  of  the  instrument,  but  by  mix  vomica.  The  death 
occurred  too  soon  to  have  been  due  to  the  presence  of  the  instrument.  It  was  proved 
that  a  midwife  of  bad  reputation  had  a  bottle  of  nux  vomica  in  her  hand  at  the  house 
on  the  day  of  the  death.  This  was  an  entirely  new  phase.  The  body  was  exhumed. 
Lassallette  was   acquitted. 

Criminal  Trial.  Two  Artery  Forceps  Found  in  Abdomen  at  Secondary  Operation. 
The  patient  was  operated  on  for  ovarian  cyst,  Dec.  22,  1897,  by  Prof.  Ivosinski  and  Dr. 
Solman,  in  the  latter 's  private  hospital.  After  a  few  days  there  appeared  fever  and 
a  mass,  which  continued.  In  the  meantime  tAvo  artery  forceps  had  been  missed,  and 
it  was  thought  they  might  be  in  the  abdomen.  The  disturbance  persisted,  and  six 
weeks  after  the  operation  the  abdomen  was  reopened  and  the  mass  of  exudate  investi- 
gated, but  neither  forceps  nor  j)us  was  found.  The  patient  was  better  afterward  and 
went  home,  but  did  not  get  well.  Later  a  hard  mass  developed  near  the  umbilicus. 
Kosinski  still  thought  the  forceps  might  be  in  the  abdomen,  and  insisted  on  another 
operation  and  offered  to  perform  it  gratis.  But  the  sons  would  not  hear  to  this,  and  the 
patient  was  taken  to  several  other  physicians,  one  after  another,  hoping  to  be  cured  with- 
out operation.  Finally,  six  months  after  the  primary  operation,  the  symptoms  became 
acute   and   threatening,   and   the   physician   who   was   called   in   insisted   that  the   patient 


FOREIGN  BODIES  LEFT  IN  ABDOMEN  1121 

be  taken  to  Kosinski  at  once,  that  he  might  perform  the  operation,  which  had  then 
become  imperative.  This  the  family  refused  to  do  and  called  in  another  physician,  who 
operated.  On  opening  into  the  mass  at  the  pelvic  brim  he  found  a  cavity  in  which  lay 
the  two  artery  forceps.  Both  forceps  had  forced  an  entrance  into  the  external  iliac  artery. 
The  removal  of  the  forceps  was  attended  with  a  furious  hemorrhage,  from  which  the 
patient  died  on  the  table. 

Legal  action  was  entered  against  Kosinski  and  there  was  an  extensive  trial,  with 
an  imposing  array  of  legal  and  medical  talent.  Six  experts  were  appointed  to  testify  in 
the  case — ^Przewoski  and  Troichij  to  consider  the  pathologico-anatomic  features,  Krajew- 
ski  to  describe  a  modern  laparotomy,  Maksimow  to  criticise  the  operation  as  performed 
in  this  case,  Pawlow  to  consider  the  various  complications  and  mistakes  that  may  occur  in 
a  laparotomy,  and  Neugebauer  to  supply  the  statistics  which  might  be  required  in  the 
trial.  It  was  for  use  in  this  trial  that  Neugebauer  compiled  the  list  of  cases  that  he 
published  the  following  year  (1900),  which  publication  has  done  so  much  to  enlighten  the 
profession  on  this  subject. 

The  trial  resulted  in  the  acquittal  of  the  accused  as  far  as  causing  the  death  of  the 
patient  was  concerned — it  having  been  shown  that  he  strongly  insisted  on  a  line  of  treat- 
ment which  would  probably  have  prevented  the  patient's  death  had  the  treatment  not 
been  peremptorily  rejected  by  the  family. 

A  curious  clinical  feature  of  this  case  was  that,  during  the  patient's  illness,  a  number 
of  radiographs  of  the  suspicious  area  were  made,  but  not  one  of  them  showed  the  forceps 
—the  failure  being  due  doubtless  to  defective  technic. 

Lawsuit.  Artery  Forceps  Extracted  From  a  Sinus.  The  patient  was  subjected  to 
operation  for  a  sarcomatous  growth  in  the  abdominal  wall  by  Dollinger.  The  patient 
was  three  months  pregnant  at  the  time  of  the  operation.  She  recovered  from  the  operation 
and  was  delivered  at  term  without  any  special  disturbance.  She  became  pregnant  again. 
Her  health  was  excellent  and  she  was  able  to  do  all  her  housework.  In  the  latter  part  of 
the  pregnancy  there  appeared  in  the  operative  scar  a  swelling,  which  opened  and  dis- 
charged much  offensive  pus.  The  abscess  was  still  further  opened  by  the  family  physician. 
Within  a  few  days  she  was  delivered.  A  few  days  after  the  delivery  an  artery  forceps 
was  discovered  in  the  abscess  wall.  The  patient  was  sent  to  the  hospital  and  the  forceps 
removed  by  operation.    The  patient  died  two  days  later. 

The  husband  of  the  patient  demanded  money  of  Dollinger,  which  demand  was  refused. 
He  then  went  to  the  public  prosecutor  and  endeavored  to  have  a  criminal  prosecution 
brought  against  the  surgeon.  The  prosecutor  asked  Dollinger  for  a  written  statement 
of  the  case,  which  was  given.  The  prosecutor  saw  no  evidence  to  warrant  criminal 
proceedings,  and  dropped  the  matter. 

The  husband  then  brought  civil  suit,  and  for  thirteen  months  Dollinger  spent  all  his 
time  defending  himself.  Sensational  reports  appeared  in  the  public  press,  and  it  is  said 
that  the  comic  papers  made  capital  of  it  and  pamphlets  on  the  subject  were  sold  at  the 
cigar  stands.  Though  acquitted,  Dollinger  suffered  irreparable  damage  from  the  sensational 
newspaper  reports  and  the  consequent  notoriety.  He  urges  strongly  that  some  means 
should  be  provided  by  which  reputable  physicians  may  protect  themselves  from  this  species 
of  blackmail  and  newspaper  persecution. 

Criminal  Trial.  Piece  of  an  Instrument  Left  in  Abdomen.  A  Paris  surgeon  lost 
part  of  a  broken  instrument  in  the  abdominal  cavity.  The  patient  died.  The  surgeon  was 
put  on  trial  for  manslaughter  due  to  negligence.     Eesult  of  trial  not  stated. 

Lawsuit.  Pair  of  Spectacles  Found  in  Abdominal  Cavity.  The  patient  had  three 
operations — the  first  in  America,  the  second  in  Germany  and  the  third  in  France.  The 
French  surgeon  found  a  pair  of  spectacles  in  the  abdomen.  The  patient  sought  redress 
in  the  courts. 


1122  MEDICO-LEGAL   POINTS   IN    GYNECOLOGY 

The  outcome  of  the  trial  is  not  given,  neither  is  it  stated  definitely  who  was  sued. 
Neugebauer,  who  cites  the  case,  blames  the  German  surgeon — noting  that  he  either  left  the 
spectacles  himself  or  missed  finding  them  if  left  by  the  previous  operator. 

Lawsuit  Threatened.  G-auze  Compress  Discharged  Per  Vaginam.  The  patient  had 
been  subjected  to  vaginal  section,  for  pelvic  suppuration,  by  MacLaren.  It  was  a  very 
severe  case.  There  was  persistent  bleeding  requiring  packing,  and  there  were  two  secondary 
hemorrhages  requiring  repeated  packing.  The  patient  recovered.  Two  months  afterward 
a  very  offensive  discharge  appeared  and  the  patient  extracted  a  twelve-inch  strip  of 
iodoform  gauze  from  the  vagina. 

Suit  was  threatened  and,  on  the  advice  of  his  attorney,  MacLaren  paid  the  patient 
a  considerable  sum  to  avoid  further  proceedings. 

Lawsuit  Threatened.  Gauze  Compress  Discharged  Per  Rectum.  The  patient  had 
uterine  fibroids,  which  Borysowicz  removed  by  abdominal  operation.  Three  weeks  later 
a  gauze  compress  was  passed  per  rectum.  Evidently  the  compress  had  been  left  in  the 
peritoneal,  cavity  at  the  time  of  the  operation.  The  patient  recovered  and  thanked  the 
operator  most  gratefully  for  his  services  and  left  him  her  photograph.  Six  years  later 
he  received  a  number  of  letters  from  the  patient's  husband,  threatening  prosecution  for 
malpractice  if  he  did  not  at  once  pay  a  certain  sum.  The  husband  had  no  doubt  heard 
of  a  lawsuit  (Kosinski's  ?)  then  on  at  "Warsaw,  and  thought  it  an  easy  way  to  obtain  some 
money  from  Borysowicz.     Apparently  nothing  came  of  the  effort. 

Lawsuit  Threatened.  Forceps  Alleged  to  Have  Been  Passed  Per  Rectum.  The 
patient  was  operated  on  for  a  suppurating  ovarian  cyst  by  Tuholske.  It  was  an  extremely 
severe  ease,  but  the  patient  recovered  and  regained  her  health  rapidly.  Twenty  months 
later  she  wrote  that  she  had  given  birth  to  a  fine  baby  and  felt  well.  Labor  had  been 
uncomplicated.  The  account  continues:  "Some  five  or  six  months  after  that  (more 
than  two  years  after  the  operation)  the  husband  called  on  me  and  stated  that  for  two  or 
three  months  his  wife  had  had  some  rectal  trouble,  supposed  to  be  piles,  and  that  a  week 
ago,  under  considerable  suffering,  she  had  passed  a  forceps  at  stool.  He  brought  it  to  me; 
it  was  a  forceps  such  as  is  usually  carried  as  dressing  forceps  in  a  pocket  case — not  a 
hemostat.  I  did  not  claim  ownership.  At  any  rate  if  that  forceps  had  been  in  the  pelvis 
for  two  and  a  half  years,  during  pregnancy  and  labor,  without  giving  rise  to  a  symptom 
or  modifying  labor,  it  was  a  remarkable  occurrence.  Three  months  after  this  episode  the 
patient  was  reported  well."  In  a  later  reference  to  the  case,  Tuholske  stated  that  several 
demands  were  made  for  money,  accompanied  by  threats  of  a  suit.  No  attention  was  paid 
to  the  demands  and  finally  they  ceased.  He  expressed  the  opinion  that  it  was  an  attempt 
to  obtain  money  by  blackmail. 

The  Question  of  Deception,  Intentional  or  Otherwise.  The  repeated  occurrence  of  this 
accident  in  the  past  and  the  possibility  of  its  occurrence  at  any  time  gives  an  opportunity 
for  designing  persons  to  obtain  money  under  false  pretenses.  Neugebauer  calls  attention 
to  this  fact,  and  remarks  that,  following  the  newspaper  publicity  given  the  Kosinski  trial, 
a  number  of  damage  suits,  alleging  the  accident,  were  filed,  and  that  in  most  instances  they 
were  cases  of  blackmail  or  extortion. 

A  case  has  been  reported  of  a  patient  who,  following  convalescence  from  an  abdominal 
operation,  expelled  pieces  of  gauze  or  thin  cloth  from  the  mouth.  The  patient  claimed 
that  the  expelled  pieces  were  vomited  sponges,  which  had  worked  their  way  into  the 
stomach  from  the  peritoneal  cavity.  Suit  was  threatened.  The  matter  was  dropped,  how- 
ever, when  the  practical  impossibility  of  the  occurrence,  as  detailed,  was  explained  to 
•the  patient. 

When  discussing  the  subject  of  foreign  bodies  left  in  the  abdominal  cavity,  a 
physician  related  to  the  author  some  of  the  details  of  a  case  in  which  he  had  been  involved. 
He  performed  an  abdominal   operation,   and,   some   time   following  the  convalescence,   the 


FOREIGN  BODIES  LEFT  IN  ABDOMEN  1123 

patient  came  to  him  and  exhibited  a  surgical  needle  and  stated  tliat  the  needle  had 
been  passed  per  rectum.  The  patient's  statement  was  confirmed  by  a  physician  who 
claimed  to  have  treated  him  at  tlie  time  the  needle  was  passed.  Suit  was  threatened. 
On  examination  of  the  needle  the  operator  found  it  was  not  the  kind  he  used  at  the  opera- 
tion, and  lie  became  convinced  that  tlie  alleged  occurrence  was  an  attempt  at  blackmail. 
The  matter  dragged  along  for  some  time.  The  operator  accumulated  all  the  information 
he  could  concerning  the  subject  and  concerning  the  parties  involved,  and  finally  confronted 
them  in  such,  a  way  that  they  were  forced  to  make  a  written  statement,  acknowledging  that 
the  needle  liad  not  been  passed  per  rectum  as  alleged.  The  needle  exhibited  had  been 
obtained  elsewhere  for  the  purpose  of  threatening  suit  and  extorting  money. 

Porter  gives  an  account  of  a  peculiar  case  bearing  on  this  subject.  Th.e  operation  was 
for  a  parovarian  cyst  and  hydrosalpinx  and  chronic  appendicitis.  The  convalescence  was 
normal  and  the  patient  left  the  hospital  twenty-two  days  after  the  operation,  feeling  well. 
Eight  days  later,  Porter  received  a  telephone  message  from  the  patient's  family  physician, 
stating  that  he  had  removed  several  pieces  of  gauze  from  her  vagina. 

Quoting  from  the  report,  "On  inquiry  from  him  I  learned  that  the  pieces  did  not  • 
tear  off,  but  came  away,  or  rather  were  removed  with  forceps, .  in  the  shape  of  rolls 
about  the  length,  and  size  of  a  lead-pencil,  and  after  all  presenting  were  removed, 
others  would  present  in  a  few  hours,  requiring  that  h.e  visit  her  two  or  three  times 
a  day  to  take  them  away.  The  doctor  thought  that  the  pieces  came  from  the  pelvic 
cavity  through  an  opening  in  the  right  side  of  the  vagina  about  the  size  of  a  lead-pencil. 
"On  the  next  day  but  one  after  learning  of  the  matter,  I  visited  the  patient  at  her 
home  with  her  doctor,  and  found  the  patient  on  a  cot  apparently  suffering  some  pain, 
which  she  said  was  due  to  more  pieces  'coming  down.'  She  did  not  look  sick.  In  reply 
to  my  question  she  said  she  felt  well  until  she  got  a  jolt  on  the  car  on  her  way 
home  and  that  since  then  she  had  been  having  pain,  which  was  worse  at  times,  and  had 
not  been  so  severe  since  the  pieces  began  to  come  away.  The  first  knowledge  the  doc- 
tor had  of  the  nature  of  the  trouble  came  through  the  patienlt's  husband,  who  told 
him  that  there  was  a  piece  of  gauze  protruding  from  the  vagina.  I  asked  to  see  what 
had  been  removed  and  was  shown  a  large  number  of  pieces  of  different  texture, 
whereupon  I  remarked  that  the  goods  were  not  such  as  I  had  used  as  sponges,  that 
there  were  more  pieces  than  had  been  used  all  told  in  the  operation,  and  that  conse- 
quently they  had  not  been  left  in  the  woman's  belly  by  me.  It  was  averred  that  they 
could  get  into  her  belly  only  through  the  wound  made  by  me  and  at  the  time  it  was 
made,  because  it  had  been  closed,  healed  by  first  intention,  and  was  still  closed.  The 
patient  facetiously  remarked  that  she  'supposed  she  swallowed  'em.'  'Xo, '  I  replied, 
'had  you  swallowed  them  they  would  not  come  out  through  the  vagina.' 

"Dr.  F.  now  asked  the  patient  if  she  thought  more  'pieces  were  down.'  Being 
answered  in  the  affirmative,  he  introduced  a  speculum  and  found  that  she  was  right. 
I  removed  the-  speculum,  and,  introducing  my  finger,  came  upon  a  small  wad  of  some- 
thing which,  upon  removal,  proved  to  be  a  piece  of  ordinary  white  muslin  about  three 
inches  wide  by  seven  long,  twisted  into  a  rope  and  doubled  upon  itself  so  as  to 
make  a  small  ball  or  wad.  It  was  perfectly  clean,  and  was  so  saturated  with  what  looked 
and  smelled  like  urine  that  on  squeezing  between  the  fingers  several  drops  were  squeezed 
out.  I  examined  the  vagina  with  my  finger,  assuring  myself  that  there  were  no  more 
'pieces'  there,  that  there  was  no  hole  leading  into  the  pelvic  cavity  and  that,  in  fact, 
it  was  a  perfectly  healthy  vagina  and  in  nowise  unusual  except  its  cleanliness,  for 
which,  of  course,  the  frequent  wij^ings  it  received  were  accountable. 

"In  the  presence  of  the  patient,  her  mother-in-law  and  the  doctor  I  said,  pointing 
my  finger  at  the  patient,  'Doctor,  I  don't  know  where  those  rags  came  from,  but  that 
woman  knows  very  well,  and  could  tell  if  she  would.'  The  mother-in-law  objected 
to  my  statement  rather  forcibly,  but  the  patient   said  nothing.     I  then  took  the   doctor 


1124  MEDICO-LEGAL   POINTS   IN   GYNECOLOGY 

outside,  told  him  that  the  woman  was  a  malingerer  and  that  we  would  give  her  a 
chance  to  put  some  more  rags  in  for  removal.  We  received  one  more  piece  before 
we  left.  Before  le'aving  I  insisted  upon  both  the  doctor  and  myself  making  a  thorough 
inspection  of  the  vagina  with  the  eye  and  the  finger  as  well.  This  was  done,  but  no 
abnormality  was  found.  It  should  be  stated  that  some  of  the  'pieces'  were  tinged  with 
blood,  but  none  of  those  removed  during  my  visit  were  so  tinged." 

Dr.  Porter  exhibited  ten  pieces  of  different  size,  shape  and  texture,  and  continued: 
"Eight  days  after  my  visit,  Dr.  Fisher  reported  'no  more  exhibits.'  So  far  as  I  know, 
no  threat  was  made  of  a  suit  for  damages,  nor  did  the  patient  or  her  mother  seem 
out  of  humor  with  me.  The  husband  was  at  work  and  not  present  during  my  visit, 
although  he  presumably  knew  the  day  before  that  I  was  to  be  there,  as  I  had  sent 
word  that  I  was  coming." 

In  regard  to  the  possible  cause  for  the  deception.  Dr.  Porter  mentioned:  1,  desire 
for  money;  2,  desire  for  sympathy;  3,  desire  to  avoid  work;  4,  sexual  perversity.  He 
stated  that  during  the  patient's  stay  in  the  hospital  nothing  pointing  to  a  neurotic  con- 
dition was  noted.     Indeed,  she  was  regarded  as  an  unusually  nice  and  agreeable  patienst. 

Schaefer  gives  the  details  of  a  case  which  emphasizes  the  fact  that  when  a  piece 
of  gauze  is  found  in  the  abdominal  cavity  it  does  not  necessarily  follow  that  it  was 
left  there  in  a  previous  operation.  The  case  occurred  in  the  practice  of  Pryce  Jones. 
Jones  was  called  to  see  a  woman  with  an  abdominal  swelling.  This  proved  to  be  an 
abscess,  which  was  opened  and  discharged  a  piece  of  cloth. 

There  had  been  no  previous  operation.  The  woman  was  insane,  and  had  been  in 
the  habit  of  tearing  up  pieces  of  cloth  and  swallowing  them.  The  swallowed  cloth 
had  evidently  caused  ulceration  of  the  stomach  wall,  with  subsequent  perforation  into 
the  peritoneal  cavity. 

The  noted  intestinal  "hair-balls,"  requiring  operation,  constitute  another  class  of 
foreign  bodies  in  the  abdomen  which  were  not  left  there  by  the  surgeon. 

Again,  the  professional  "knife  swallowers"  and  "glass  eaters"  and  their  ama- 
teur imitators  must  be  kept  in  mind.  Fortunately  the  menu  of  these  persons  is  limited, 
as  a  rule,  to  household  articles.  However,  some  such  "actor,"  who  has  been  relieved 
of  his  accumulated  load  by  surgical  art,  might,  from  the  intimate  acquaintance,  ac- 
quire a  taste  for  surgical  forceps  instead  of  the  usual  nails  and  pocket-knives.  In 
that  case  a  condition  might  easily  develop  that  would  make  it  very  uncomfortable  for 
the  previous  operator,  though  wholly  without  fault  on  his  part. 

To  make  absolutely  certain  that  no  sponge  or  other  foreign  body  is  left  in 
the  peritoneal  cavity  at  operation  is  a  hard  problem.  The  solution  of  this 
problem  is  considered  on  pages  1077  to  1082. 


OTHER  CONDITIONS 

Presenting  Medico-Legal  Points 

1.  The  various  medico-legal  questions  concerned  with  the  state  of  preg- 
nancy, abortion,  labor  and  the  puerperium  belong  more  strictly  to  obstetrics, 
and  need  not  be  considered  here. 

2.  The  question  of  the  character  of  a  disease  present — particularly  gonor- 
rhea, syphilis,  or  chancroid — and  the  source  from  which  it  could  have  come, 
and  whether  or  not  it  is  still  transmissible,  are  all  questions  that  may  assume 
medico-legal  importance  under  various  circumstances;  for  example,  in  suits 


MEDICO-LEGAL   POINTS   IN    GYNECOLOGY  1125 

for  divorce,  suits  for  possession  of  children,  suits  for  alimony,  suits  for  dam- 
ages against  individuals  or  corporations,  etc.  Also,  of  injuries  of  tlie  genital 
organs  you  may  be  called  to  give  the  nature,  extent,  possible  cause  and  prob- 
able outcome.  All  these  are  simple  clinical  questions,  and  the  information 
regarding  them  may  be  obtained  from  the  clinical  portions  of  this  work. 

3.  Various  questions  in  regard  to  sterility  may  come  up  in  legal  inquiries. 
The  required  information  on  this  subject  is  given  in  Chapter  xiv. 

4.  In  the  case  of  the  death  of  a  woman  or  girl  under  suspicious  circum- 
stances, the  physician  may  be  called  upon  to  make  a  postmortem  examination 
and  then  to  answer,  as  far  as  possible,  various  questions,  among  which  may  be 
the  following : 

■    What  pelvic  lesions  were  present? 
What  was  the  probable  cause  of  these  lesions? 
What  was  the  cause  of  death? 

5.  In  coroner's  cases,  and  much  more  so  in  malpractice  suits  (before  or 
after  death),  the  following  questions  may  be  asked  concerning  almost  any 
gynecologic  disease : 

What  disease  is  present? 

What  are  the  principal  points  upon  which  your  diagnosis  is  based? 

In  your  opinion  did  the  attending  physician  use  reasonable  care  and 

skill  in  the  diagnosis? 
What  is  the  established  treatment  for  the  disease? 
In  your  opinion  did  the  attending  physician  use  reasonable  care  and 

skill  in  the  treatment? 

6.  In  criminal  cases  and  in  damage  suits  the  physician  testifying  as  an 
expert  may  be  required,  particularly  in  the  cross-examination,  to  explain  in 
detail  various  points  in  the  etiology,  pathology,  symptomatology,  diagnosis, 
treatment  and  prognosis  of  the  affection  under  consideration.  To  answer  such 
questions,  the  physician  must  be  well  grounded  in  all  the  important  facta  and 
theories  of  the  disease,  and  must  be  able  to  give  the  required  explanations  in 
a  few  words  and  in  ordinary  language,  avoiding  the  little-understood  tech- 
nical terms. 

On  important  contested  points  it  is  well  to  be  fortified  "with  the  names  of 
two  or  three  recognized  authorities  on  that  particular  subject,  with  their 
exact  statements.  This  information  is,  of  course,  held  in  reserve,  to  be  given 
only  if  requested. 


INDEX 

DIAGNOSTIC,  THEEAPEUTIC   AXD   GENERAL   INDEX 

Note. — Under  "Examination,  gynecologic,"  (page  1138),  the  references  are  arranged 
systematically  as  in  the  text,  instead  of  alphabetically.  Following  this,  under  "Examination" 
(page  lliO),  the  references  are  arranged  also  alphalDctically. 


A 

Aljdomen,  46,  164 
auscultation  of,   60 
contour  of,  46,  164 
discoloration  of,  46,  181 
disinfection  of,  1069 
distention  of,  172 
dullness  in,  59,  195 
from  ascites,    196 
from  bladder,   193 
from  kidney  tumor,   207 
from  liver,    195 
from  ovarian  tumor,  205 
from  perirenal  tumor,  208 
from  retroperitoneal  tumor,  206 
from  spleen,   195 
from  tubal  mass,  204 
from  uterine  fibroid,  205 
examination  of,  46,  163 
exploration  of,  775 
foreign  bodies  in,  1077,  1118 
in  ascites,  174,  196 

in   gj-necologic   diagnosis,    163    {See    Diag- 
nosis) 
in  obesity,  164 
in  pregnancy,  176 
in  tumors,   167 
in  tjTapanites,  172 
inspection  of,  46 
mass  in,  56,  291 

in  central  lower,  191,  320,  325 
-      in  left  lower,  191,  299 
in  right  lower,  191,  296 
in  central  upper,  194 
in  left  upper,  194 
in  right  upper,  192 
mensuration  of,  61 
movements  of,  181 
palpation  of,  46,  191 
percussion  of,  59 
prominence  of,  46,  164 
regions  of,  49 
right  lower,  51,  191 
shape  of,  47,  164 
in  ascites,  174 
sterilization  of,  1069 
tenderness  in,  46,  183 
tension  of,  46,  182 
tumor  of,  180  '        '        ' 


Abdominal  adhesions,   838 
antisepsis,  1069 

applications,    352    {See  Applications) 
bandage,  1092 
diagnosis,  164,  307,  327 
drainage,  817,  1076 
dressing,  1075 

drainage  cases,  1095 
ordinary  eases,  1075,  1095 
septic  cases,  1096 
sterilization,   1069 
examination,  46,  162    {See  Examination) 
gynecologic  examination,  46,  162    {See  Ex- 
amination) 
hernia,   169 

hysterectomy,  733,  751 
incision,  1074   {See  Incision) 

closure  of,  1075 
myomectomy,  733,  751 
operation,  1065 
palpation,  46,  191 
section,  1065 

after-care  in,  1089 
after-treatment    of,    1089 

bandage,  1092 

bladder,   1090 

bowels,  1090 

by  days,  1089 

constipation,   1100 

diet,   1090 

dilatation  of  stomach,  1099 

drainage,   1095 

dressings,  1092 

drink,  1090 

exercise,   1093 

first  day,  1089 

fistula,  1103 

fourth  day,  1091 

Fowler  posture,  828,  1098 

hemorrhage,  1098 

hernia,  1103 

internal  hemorrhage,   1098 

intestinal  obstruction,  1100 

intestinal  paralysis,  1100 

kidney  insufficiency,  1100 

laxatives,   1090,  1100 

local  suppuration,  1101 

nausea,  1099 

orders,  1091 

pain,  1090,  1102 


111 


1128 


INDEX 


Abdominal  section, — Cont  'd 

peritonitis,  1100 

phlebitis,  1102 

position,  1090,  1098 

pulse,  1098 

regular,  1089 

removing  sutures,  1092 

restlessness,  1090 

second  day,  1090  • 

sedatives,  1090 

shock,  1098 

sinus,  1103 

sitting  up,  1093 

special  conditions,  1095 

stimulants,  1098 

strapping,  1092 

strychnia,  1098 

subsequent  orders,   1091 

sutures,  1092 

temperature,   1101 

third  day,  1090 

thirst,  1090 

tympany,  1099 

uterine  replacement  cases,  1098 

vomiting,  1098,  1099 

walking,  1093 

wound,  1092 
anesthesia  in,  1073 
bandage  in,  1075 
contraindications  for,  1066 
dangers  in,  1067 
drainage  in,  1095 
dressings  after,  1075,  1095 
exploratory,  1065 
indications  for,  1066 
position  of  arms  during,  1073 
preparations   for,   1067 

assistants,  1071 

diet,  1069 

disinfection,  1069 

dressings,  1070 

examination,   1068 

face  mask,  1072 

general,  1067 

gowns,  1071 

hand   disinfection,   1072 

in  home,  1067 

instruments,    1070 

kidneys,  1068 

laxatives,  1069 

nervous  system,  1068 

operative  field,  1071 

patient,  1068 

rubber  gloves,  1071 

sleeves,  1071 

sponges,  1071 

sterilization,  1069 

surface  of  abdomen,   1069 

sutures,  1070 

take  to  hospital,  1067 
regular  steps  in,  1073 

anesthesia,  1073 

closure  of  incision,  1075 

correction  of  pathologic  condition,  1075 

dressing,  1075 


Abdominal  section  in, — Cont'd 
exploration,  1075 
incision,  1074 
toilet  of  peritoneum,  1075 

rubber  gloves  in,  1071 
special  points  in,  1076 

drainage,  1076 

injuries,  1077 

instruments  left,  1077 

shock,  1076 

sponges  left,  1077 
sponges,  1080 
supporter,  1093 
surface,  sterilization  of,  1069 
touch,  46 
wall,  46,  164 

abscess,  167 

fat,  164 

inflammatory  mass  in,  167 

movement  of,  181 

relaxation,  169 

separation  of  recti,  170 

skin,  46 

tumor,  164 
wound,  1074 

infection  of,1101 

strapping  of,  1092 

suppuration  of,  1101 

sutures  in,  1070,  1092 
Abdomino -rectal  examination,  107 
Abdomino-vaginal  examination,  83 
Abnormal  pregnancy,  279,  286,  289 
Abortion,  218 

criminal,  38,  1124 
incomplete,  38 

metrorrhagia  from,   38,  1031 
tubal,  877 
Abscess,  814,  834 
appendiceal,  308 

broad  ligament,  293,  296,  819,  844 
ischio-rectal,  291 
of   abdominal   wall,    167     {See    Abdominal 

wall) 
of  Bartholin's  glands,  64,  239,  496 
of  vulvo-vaginal  gland,  64,  239,  496 
ovarian,  308,   808 
pelvic,  291,  808 

acute,  807,  819 

after-treatment,   820 

appendiceal,  184,   308 

bacteria,  807,  853,  854 

broad  ligament,   293,  820 

chronic,  833 

diagnosis,  711,  840 

diffuse,  302,  808,  835 

drainage,  817 

drainage  tubes,  818 

gonococcal,  854 

opening,  817 

ovarian,  808,  836 

prognosis,  831 

streptococcal,   859 

treatment,    813,    850 

tubal,  808,  835 

tubo-ovarian,  808,  836 


INDEX 


1129 


Abscess, — Cont  'd 

j^uerpoial,  bacteria  in,  831 
stilch-hole,   1101 
suburethral,  251,  492 
tubal,  808,  834 
urethral,  64,  251,  492 
vulvo-vaginal;  33,  233,  496 
Alisence   of  hymen,   1114 
of  uterus,  979 
of  vagina,  222,  966 
Accessory  Fallopian  tubes,  874 

ovary,  965 
Acid,  oxalic,  1072 
Action  of  pessaries,  372 
Acute  dilatation  of  stomach,  1099 
endocervicitis,  603 
endometritis,   633 
metritis,  633 
pelvic  inflammation,  807 
cellulitis,  808 
oophoritis,  808 
operation  for,  814 
ovaritis,  808 
peritonitis,   808 
salpingitis,  808 
treatment,  813 
urethritis,  64,  492 
vaginitis,  463,  468 
vulvitis,  468 
Adenitis,  inguinal,  477 
Adenocarcinoma  of  cervix  uteri,  334,  755 

of  corpus  uteri,  283,  789 
Adenomyoma  of  uterus,   706 
Adherent  labia  minora,  222,  525 
prepuce,  222,  525 
retrodisplacement,  677 
Adhesions,  838 
abdominal,  838 
of  clitoris,  222 
of  external  genitals,  525 
of  Fallopian  tubes,   838 
of  intestines,  838 
of  labia,  222,  525 
of  ovaries,  838 
of  prepuce,  222,  525 
of  uterus,  682 
of  vaginal  walls,  468,  966 
postoperative,  1100 
tubercular,  869,  872 
Adhesive  plaster,  1092 

vaginitis,  468 
Adjustable  foot-rests,  139 

leg-holders,  139 
Adrenal  bodies,  relation  to  gynecology,  1048 
Adult,  endometrium  of,  584 
After-care   in    abdominal    section,    1089    (See 

Abdominal  section) 
After-treatment,  1098 
for  repair  of  cervix,  619 
for  repair  of  pelvic  floor,  555 
in  abdominal  section,  1089   (See  Alidominal 

section) 
in  curetment,  655 
in  operative  cases,  1089 
in  pelvic  abscess,  820    (See  Abscess) 


After-treatment, — Cont  'd 

in  pelvic  drainage,  828,  1095 
in  perineorrhaphy,  555 
in  trachelorrhaphy,  619 
in  vaginal  section,  1103 
Agents,  antiseptic,  140 
Albicans,  corpus,  916 
Alcohol,  149 

Alexander-Adams  operation,  686 
Amenorrhea,  976 
causes  of,  977 
classes  of,  977 
diagnosis  of,  976 
in  the  virgin,  977 
symptoms  of,  976 
treatment  of,  979,  986 
Ampullar  pregnancy,  875 
Amputation  of  Fallopian  tubes,  1085 
of  cervix  uteri,  625 
of  corpus  uteri,  1088 
partial,  of  cervix  uteri,  621 
supravaginal,  733  1087 
Amyloid  degeneration  of  fibroid,  720 
Anal  iissure,  79 

Anatomy  of  Bartholin 's  glands,  64,  425 
of  endometrium,  583 
of  external  genitals,  62,  209 
of  Fallopian  tubes,  799 
of  hynien,  209,  425 
of  ovary,  910 
of  parovai'ium,  922 
of  pelvic  connective  tissue.   805 
of  pelvic  floor,  527 
of  pelvic  peritoneum,  804 
of  peritoneum,   593 
of  round  ligament,  593 
of  urethra,  424 
of  uterus,  577 
of  vagina,  427 
of  vulva,  209,  421 
of  A'Ulvo-vaginal  gland,   64.  425 
pelvic,   33,   577,    799 
Anemia,  blood  examination  in,  153 
Anesthesia,  1073 
ether  in,  1073 
for  diagnosis,  127 
for  examination,  127 
for  operation,  1073 
general,  127 

gynecologic  examination  under,  127 
in  abdominal  section,  1073   (See  Alidominal 

section) 
local,  106,  365 
paralysis  from,   1073 
position  of  arms  in,  1073 
preparation  for,  1068 
scopolamin  in,  903 
Ani  muscle,  levator,  528 

sphincter,  539 
Animal  extracts,  418 
Anodynes,  106 
Anomalies,  964 

of  bladder,  179.  965 

of  Fallopian  tubes.  873,  965 

of  hymen,  209,  966 


1130 


INDEX 


Anomalies, — Cont  'd 

of  ovaries,  965 

of  urethra,  965 

of  uterus,  966 

of  vagina,  222,  966 

of  vulva,  222,  965 
Anus,  79 
Anteflexion,   congenital,   271,   702 

of  cervix,  operation  for,  1010 
Anterior  colporrhaphy,  558 

vaginal  section,  1082 
Antero-posterior  section  of  pelvis,  34,  35 
Anteversion,   703 
Antisepsis,   abdominal,   1069 

in  examinations,  140 

vaginal,  648 
Antiseptic  agents,  140 

preparations  for  examination,  140 
Aphthae  of  vagina,  466 
Apostoli  method,  729 
Appendiceal  abscess,  308 
Appendicitis,  185,  812 
Appendix,  diseases  of,  308 

vermiform,  308 
Applications,  348 

abdominal,  352 

cervical,  353 

cold,  351 

counterirritant,  352 

dry  heat,  350 

for  endometritis,  637,  643 

hot,  348 

intrauterine,   391 

moist  heat,  348 

rectal,  404 

vaginal,  353 

concentrated  solutions,  364 
douches,  353 
powders,  366 
suppositories,  367 
tablets,   367 
tampon-capsules,  371 
tampons,  368 

vulvar,  353,  364 
Apron,  Hottentot,  242 

Arms,  position  of,  during  abdominal   section, 
1073    {See  Abdominal  section) 

position  of,  in   anesthesia,   1073 
Arrangements,  office,  138 
Artery  forceps,  543 
Ascites,  174 

abdomen  in,  174,  196 

diagnosis  of,  174,  197 

dullness  in,  198 

percussion  of  abdomen  in,  197 

shape  of  abdomen  in,  174 

signs  of,  197 

wave  in,  58 
Asepsis  in  intrauterine  examination,  141 

in  operations,  1069 
abdominal,  1069 
vaginal,  1084 

in  vaginal  examination,  141 
Aseptic  fever,  1102 


Assault,  indecent,  1108 
Assistant  in  office,  139 

in  operations,  1071 
Astringents,  364,  417 
Atmocausis  of  Pincus,  398 
Atresia,  congenital,  of  cervix,  282 

congenital,  of  vagina,  222 

of  cervix,  282,  298 

of  hymen,  222 

of  uterus,  282 

of  vagina,  222,  966 

of  vulva,  222 
Atrophy  of  uterus,  659 
Auscultation,  60 

in  pregnancy,   60 

of  abdomen,  60 

B 

Bacillus,  Ducrey,  472 

Backache  in  gynecologic  diagnosis,   343    {See 

Diagnosis) 
Bacteria,  435,  633 

in  cellulitis,  860 

in  endometritis,  633 

in  pelvic   abscess,    807,   853,   854    {See  Ab- 
scess) 

in  peritonitis,  807 

in  puerperal  abscess,  854 

in  pyemia,   854 

in  pyosalpinx,  854 

in  salpingitis,  854 

in  thrombo-phlebitis,  809 

in  urethritis,  65 

in  uterus,  633 

in  vagina,  431,  463 

in  vaginitis,  463 
Bacteriologic  examination,  QQ 

for  gonococci,  435 

gynecologic,  QQ 

securing  discharge  for,  65 
Bag,  hot-water,  350 

ice,  351 
Bandage,  654,  1092 

abdominal,  1092 

in    abdominal    section,    1092    {See    Abdom- 
inal section) 

T,  654 
Bartholin's  glands,  64,  425 

abscess  of,  239,  496 

anatomy  of,  64,  425 

examination  of, 

palpation  of,  &Q 
Bathing  in  gynecologic  treatment,  412 
Bed,  examination  in,  145 
Bed-pan,  360 
Bieornuate  uterus,  968 
Bimanual  examination,  83,  275  - 

gynecologic,  83 

of  uterus,  84 

of  virgin,  108 

palpation,  84,  275 

replacement,  678 
Bivalve  speculum,  111 


INDEX 


1131 


Bladder,  anomalies  of,  179,  965 

carcinoma  of,  178 

caie  of,  555,  1089,  1105 

catheterization  of,  1105 

diseases  of,  303 

displacements   of,   725 

distended,  179 

drainage  of,  576 

extrophy  of,  178 

injuries  of,  1077 

malformation  of,  179 

prolapse  of,  228,  265 

rupture  of,  179 
Bleeding  in  menopause,  975 

senile,  975 
Blood,  153 

examination  of,  153 

retention   of,   222 

supply  of  vulva,  426 

vessels  of  external  genitals,  426 
of  ovary,  591 
of  pelvic  floor,   529 
of  tubes,  803 
of  uterus,  590 
of  vagina,  430 
of  vulva,  426 
Bloody  discharge,  65,  1030 

causes  of,  1030 

treatment  of,  1032 
Body,  Wolffian,   960 
Boiling,  141 

gloves,  147,  1070 

instruments,   141,   1070 

towels,  1070 
Bowels   after   operation,   557 

before   operation,   1069 

obstruction  of,  1100 

in  pelvic  affections,  813,  1069 
Broad  ligament,  593 

abscess,  293,  296,  819,  844 

cyst  of,  297,  955 

hematoma  of,  295 

thrombosis,  809 

tumor  of,  312 

vaiicose  veins  of,  908 
Brushes,  144 

hand,  144 

in  examination,  144 
Bubo,  474 
Buried  sutures,  553 
Byrne's  cauterization  method,  788 

C 

Cachexia,  771 

Caesarean  section,   751 

Calcareous  degeneration  of  fetus,  321 

Calcification,  720 

Calculi  of  ureters,  293 

of  veins,  908 
Calculus,   ureteral,   292 
Canal  of  cervix,  578,  755 

of  Gartner,  961 

of  Nuck,  510 


Cancer  cases,  classification  of,   755 
curetment  in,   786 
metrorrhagia  from,   766 
of  cervix  uteri,   755 
of  corpus  uteri,   755 
of  ovary,  953 
of  uterus,  285,  334,  755 
of  uterus,   operation  for,   775 
of  uterus,  radical   treatment   for,  773 
X-ray  in,  390,  788 
Cantharides  collodion,  352 

plaster,  352 
Capillary  drainage,  1095 
Carcinoma,  cervical,  755 

complicating  pregnancy,    784 
of  cervix  uteri,  755 
diagnosis,  766 
duration,  766 
etiology,  755 
extension,  762 
hemorrhage,  771 
metastases,   765 
operability,  773 
operation,  775 
palliative  treatment,   785 
pathology,  755 
recurrence,   784 
SAinptoms,  766 
treatment,  773 
varieties,   758 
X-ray  treatment,   788 
of.  clitoris,  221 
of  corpus  uteri,  789 
diagnosis,  792 
symptoms,    792 
treatment,    792 
of  endometrium,  789 
of  Tallopian   tube,   907 
of  ovary,  953 
of  rectum,   762 
of  urethra,   487 
of  uterus,    755 
of  vagina,  488 
of  vulva,  222,  487 
of  vulvo -vaginal  gland,  245 
Cards,  history,  43 
Care  of  bladder,  555,  1089,  1105 

of  pessaries,  382 
Caruncle  of  external  genitals,  494 
urethral,  494 

diagnosis  of,  495 
treatment  of,  495 
Case  I'ecord,  42 
(^atarrh,  cervical,  606 
Catgut  sutures,  553 
Catheterization,  1105 
Catheters,   sterilization   of,   1105 
Cauliflower  excrescence,  337 
Causes  of  amenorrhea,  976 
of  bloody  discharge,  1030 
of  cystocele,   559 
of  dysmenorrhea,  996,  1014 
of  endocervicitis,  604 
of  endometritis,  663,  638 
of  eversion  of  cervical  mucosa,  60S 


1132 


INDEX 


Causes, — Cont'd 

of  extrauterine   pregnancy,    873 
of  fibromyoma,  704 
of  gonorrhea,  431 
of  kraurosis  vulvae,  516 
of  leucorrhea,  213,  1026 
of  menorrhagia,   988 
of  metrorrhagia,  1030 
of  papillary  cysts,  931 
of  peritonitis,  807 
of  pruritis  vulvae,   518 
of  retrodisplacement,    671 
of  salpingitis,  807,  834 
of  shock,  1076 
of  sterility,  1021 
of  tubal  pregnancy,   873 
of  vaginitis,  431,  463 
of  vulvitis,  431,  451 
Cauterization,   397 
intrauterine,  397 
chemical,  398 
electric,  398 
steam,  398 
method,  Byrne's,  788 
Cautery,  Paquelin,  786 
Cecum,  diseases  of,   309 
Celiotomy,  1065 
Cellulitis,  bacteria  in,  860 
pelvic,  808,  843 
vulvar,  456 
Cervical  applications,  353 
canal,  mass  in,  275 
carcinoma,  755 
catarrh,  606 
cyst,  622 
dilatation,  404 
incision,  closure  of,  618 
mucosa,  epithelium  of,  597 

eversion  of,  608 
myoma,  704 
polypi,  606,  625 

hemorrhage  in,  625 
wound,  infection  of,  620 
Cervix  uteri,  adenocarcinoma  of,  755 
amputation  of,  620 
anatomy  of,  587 
atresia  of,  282,  298 
canal  of,  578 
cancer  of,  755  ^ 

carcinoma  of,  755   (See  Carcinoma) 
classification  of  diseases,  597 
conditions  of,  334 
congenital  atresia  of,  282 
cystic  degeneration  of,  607,  621 
dilatation  of,  125,  404,  648 
ectropion  of,  273 
elongation  of,  624 

Emmet 's  operation  for  lacerated,  613 
endocervicitis,  603 
epithelioma  of,    755 
erosion  of,  598 
eversion  of,  270 
examination  of,  80,  270 
fibroid,  710 


Cervix  uteri, — Cont  'd 

follicular   degeneration   of,   606     ' 

glands  of,  585 

hypertrophy  of,  624 

in    gynecologic    diagnosis,    270,    334     (See 

Diagnosis) 
infection  of,  603 
injuries  of,  608 
inspection  of,  216 

lacerations  of,  608   (See  Lacerations) 
malformation  of,  290 
malignant  disease  of,  755 
nodule  in,  271 
occlusion  of,  290 
operations,  denudation  in,  617 
for  anteflexion,  1010 
technic  of,  613,  620    (See  Technie) 
partial  amputation  of,  621 
polypi  of,  606,  625 
repair  of,  incision  for,  613    (See  Incision) 

instruments  for,  615 
Schroeder's  operation  on,  623 
stenosis  of,  605 
sutures  in,  617 
trachelorrhaphy,  613 
ulcer  of,  601 
Chafing,   459 
Chancre,  472 

soft,  472 
Chancroid,  472 

of  external  genitals,  472 
of  vagina,  472 
of  vulva,  219,  472 
phagedenic,  477 
Chancroidal  adenitis,  477 
Chancroidal  virus,  475 
Change  of  life,  975 

Chapter   on   gynecologic   diagnosis,   163    (See 
Diagnosis) 
on  gynecologic  examination,  33 
Chemical  nature  of  internal  secretion,  1037 
Children,   gonorrhea  in,   450 
leucorrhea  in,  465 
rape  of,  1110 
vaginitis  in,  465 
Chorioepithelioma,  789 
Chronic  endocervicitis,  606 
endometritis,  639 
gonorrhea,  440 
metritis,  638 
pelvic  inflammation,  833 
bacteriology  of,  852 
cellulitis,  843 
oophoritis,  846 
ovaritis,  846 
peritonitis,  833 
salpingitis,  834 
treatment  of,  850 
urethritis,  492 
vaginitis,  446,  465 
vulvitis,  454 
Cirrhosis  of  ovary,  841 

of  uterus,  660 
Classes  of  amenorrhea,  977 
Classification  of  cancer  cases,  755 


INDEX 


1133 


Classification, — Cont  'd. 

of  causes  of  displacement,  671 

of  diagnostic  signs,  327 

of  diseases,  431 

of  endometritis,  633 
•  of  examination  methods.  14 

of  fibroid  cases,  709,  710 

of  flbromyoma,   704 

of  fistulae,  561 

of  operations  for  displacement,  686 

of  retrodisplacement  cases,  686 

of  therapeutic  measures,    345 

of  tumors  of  ovary,  922 

of    vulvar  diseases,  431 
Cleansing   soap,   144 
Climacteric,    975 
Clitoris,  423 

adhesions  of,  222 

carcinoma  of,  221 

cyst   of,  248 

hvpertrophv  of,  239,  243 

malformation  of,  222,  239 
Closure  of  abdominal  incision,  1075 

of  cervical  incision,  618 

of  perineal  incision,  555 
Cocaine,  365 
Coccygodynia,  342 
Coccyx,  examination  of,  110 

palpation  of,  110 
Codeine,  556 
Coitus,  difficult,  1017 

obstruction  to,  1017 

pain  in,  1018 

violence  in,  228 
Cold  in  gynecologic  treatment,  351 
Cold-Avater  coil,  351 
Collodion,  141 
ColpeurAmter,  411 
Colpoceie,  228,  538,  558 
Compresses,    349,    351 
Conception,  1020 
Condylomata,  231,  499 

excision  of,  501 

multiple,  499 

of  external  genitals,  499 

of  vulva,  231,  499 
Cones,  vao"inal,  367 
Congenital  anteflexion.  271,   702 
atresia   of   cervix,   282 
atresia   of   vagina,   222 

malformations,  222,  960 
Congestion  of  pelvis,  989 
Congestive  dysmenorrhea,  994 
Conservative  operation  in  salpingitis,  1085 
on  Fallopian  tubes,  1085 
surgery,  definition  for,  1085 
indications  for,  1085 
of  Fallopian  tubes,  1085 
of  ovaries,  1085 
of  uterus,  1085 
reasons  for.  1085 
Constipation,  1100 
Constitutional  treatment,  979 
Constriction,  waist,  413 
Continuous  sutures,  553 


Contour  of  abdomen,  46 

Contraindications  for  abdominal  section,  1066 
{See  Abdominal  section) 
for  curetment,  127 
for  operation,  1066 
to  marriage,  432 
Contusion  of  vulva,  515 

pain  during,  1102 
Corona  of  resonance,  194 
Corpus  albicans,  916 
luteum,  916 
luteum,  cyst  of,  925 
uteri,  597 

adenocarcinoma  of,  789 
amputation  of,  1088 
cancer  of,  789 

carcinoma  of,  789   {See  Carcinoma) 
classification  of  diseases  of,  597 
infection  of,  633 

in  gA-necologic  diagnosis   {See  Diagnosis) 
malignant  disease  of,  789 
Corrections,  dress,  413 
Corset,  413 
Counterirritation    in     gynecologic    treatment, 

352 
Crab  louse,  462 
Crede's  ointment,  395 
Criminal  abortion,  38,  1124 

trials.  1124 
Crossen's  gauze-strip  sponges,  1080 

puncturing  tenaculum  forceps,   692 

retrodisplacement  operation,  692 
Crown  sutui'e,  553 
Cul-de-sac  of  Douglas,  35,  36 
Cup  and  belt  pessaries,  390 
Curet,  125,  650 

examination  with,  125,  134 

uterine,  125,  650 
Curetment,  134,  644 

after-treatment  in,  655 

contraindications  for,  127 

dangers  of,  127 

diagnostic,  125,  134 

effects  of,  655 
•   exploratory,   125,   134 

for  endometritis,  644 

in  cancer,  786 

in  doubtful  cases,  134 

in  endometritis,  644 

in  fibromyoma,  729 

in  tuberculosis,  665 

indications  for,   134 

instruments  for,  645 

preparation  for,  645 

steps  in,  646 

technic  of,  646 

therapeutic,   642 
Curettage   {See  Curetment) 
Curetting,    microscopic    examination    of,    134, 

-  769 
Cylindrical  speculum,  119 
Cyst,  cervical,  622 

corpus  luteum,  925 

dermoid,  939 

follicular,  923 


1134 


IXDEX 


Cyst,— Cont'd 

liYclatid,  667 

intraligamentary,  297 

mesenteric,  180 

multilocular   ovarian,   936 

of  broad  ligament,  297,  955 

of  clitoris,  248 

of  corpus  luteum,  925 

of  external  genitals,  503 

of  Morgag-ni,  922 

of  vagina,   503 

of  Tnlva,  503 

of  Yulvo-vaginal  gland,  498 

ovarian,  923 

pancreatic,  180 

papillary,  931 

parovarian,  955 

proliferating,    926 

pseudomucinous,   927 

rupture  of,  947 

serous,  of  ovary,  931 

tubo-ovarian,   925 

vaginal,  261 

vulvo-vaginal,  498 
Cystadenomata  of  ovarv,   927 
Cystic  degeneration,  606 

of  cervix  uteri,  607,  621 

of  fibroid,  720 
Cj^stocele,  228,  538,  559 

causes  of,  559 

diagnosis  of,  228,  559 

oyjeration,  technic  of,  559 

pessaries  for,  389 

treatment  of,  559 

D 

Dam,    rubber,    1095 

Dangers  in  abdominal  section,  1067   (See  Ab- 
dominal section) 

of  curetment,   127 
Debility,  general,  153 
Decidual  remnants,  137 
Deep  percussion  of  abdomen,  59 
Degeneration,   calcareous,   of   fetus,   321 

cystic,  of  cervix,  606 
of  fibroid,  720 
of  ovary,  923 

fatty,  720 

follicular,  of  cervix,  606 

malignant,  755 

myxomatous,  720 

of  fibroids,  720 
.  Delayed  menstruation,  976 
Delayed    puberty,   relation   to   internal   secre- 
tion, 1052 
Denudation  for  repair  of  cervix,   617 

for  repair  of  pelvic  floor,  552 

in  cervix  operations,  617 

in  fistula,  570 

in  pelvic  floor  operations,  552 
Dermatitis,  451 
Dermoid  cyst  of  ovary,  939 
Detached  sponges,  1080 


Development  of  Fallopian  tubes,  963 
of  h;\Tnen,  961 
of  ovaries,  963 
of  uterus,  669,  962 
of  vagina,  962 
Diabetes  mellitus,   153 
Diagnosis,  abdominal,  164,  307,  327 
anesthesia  for,  127 
gynecologic,  163 
abdomen   in,    164 
discoloration,   181 
dullness,  195 
mass,  191 
movement,  181 
prominence,  164 
tenderness,  183 
tension,  182 
backache  in,   343 
cervix  uteri  in,  270,  334 
discharge,   334 
displacement,  84,  270 
distortion,  270 
enlargement,  270 
erosion,  334 
eversion  of  mucosa,  608 
fixation,  272 
hardening,  271 
laceration,  611 
mass  in  canal,  270 
softening,  270 
tenderness,  272 
corpus  uteri  in,  88,  275 
displacement,  88,  275 
enlargement,  88,  280 
fixation,   88,  290 
hard  nodules,  288 
softening,  89,  282 
tenderness,  89,  288 
methods  of,  163 
pain  in   pelvis   in,    337 
pelvic  mass  in,  291,  327 
mass  high  in  pelvis,   307 
in  center,  firm,  320 
in  center,  fluid,  325 
in  left  side,  fimi,  320 
in  left  side,  fluid,  320 
in  right  side,  firm,  307 
in  right  side,  fluid,  313 
mass  low  in   pelvis,   291 
liehind  cervix,  firm.  299 
behind  cervix,  fluid,  301 
in  front  of  cervix,  firm,  303 
in  front  of  cervix,  fluid,  303 
.     filling  pelvis,  firm,   305 
filling  pelvis,  fluid,  307 
to  left  of  cervix,  firm,  299 
to  left  of  cervix,  fluid,  301 
to  right   of   cervix,  firm,  291 
to  right   of   cervix,   fluid,   296 
table  for,  327 
vaginal,  261 

bleeding  area,   330 
congestion,  330 
mass,  263 
roughening,  261 


INDEX 


1135 


Diagnosis,    gynecologic,   vaginal, — Cont  'd 
tenderness,  262 
ulcer,   330 
vulvar,  261 
discharge,  212 
inflammation,  217 
laceration,  222 
malformation,   222 
swelling,  22S 
ulcer,  219 
method  of,  163 
of  amenorrhea,  976 
of  ascites,  174   {See  Ascites) 
of  chancroid,  475 
of  cystocele,  228 
of  endometritis,   634,  637 
of  extrauterine  i^regnancv,  882 
of  fibromyoma,  724 
of  gonorrhea,  434 
of  imperforate  hymen,  224,  'i^QQ 
of  kraurosis   vulvae,   218,  517 
of  menopause,   975 
of  menorrhagia,  989 
of  menstruation,  974 
of  metrorrhagia,  1035 
of  ovarian  cysts,  939 
of  peritonitis,  811 
of  pregnancy,  159 
of  pruritus  vulvae,  51S 
of  retrodisplacement,   675 
of  salpingitis,  811,  840 

of  suppuration   of   abdominal   wound,   1101 
of  tubal  pregnancy,  882 
of  urethral   caruncle,   243,   494 
of  vaginitis,  434,  465 
of  vulvitis,   218,  452 
Diagnostic  curetment,  125,  134 
signs,  classiflcation  of,  327 
table  of  questions,  327 
Diagrams  in  records,  43 
Diet,  420 

Differential  diagnosis,  327 
Difficult  coitus,  1017 
Diffuse  fibromyoma,  710 
Digital  examination,  69,  262 
rectal,    128 
uterine,  136 
vaginal,  69 
palpation,  69,  262 
Dilatation,   69,   262 

acute,  of   stomach,  1099 
of  cervix  uteri,  125,  648 
of  vaginal  orifice,  524 
Dilating  forceps,  126,  644 

tents.  127 
Dilators,  uterine,  126,  644 
Diphtheritic    vaginitis,    467 
Diphtheritic  vulvitis,  457 
Diplocoeeus  of  gonorrhea,  437 
Directions  for   giving  nutritive   cnemata,   830 
Discharge,  63,  212 
bloody,  65,  1030 
causes  of,  1030 
treatment  of,  1032 
from  vulvo-vaginal  gland,  67 


Discharge, — Cont  'd 
muco-epiithelial,   62 
muco-purulent,  63 
purulent,  63 

securing,  for  bacteriologic   examination,   6^ 
urethral,   65 
watery,  QQi 
Discoloration  of  abdomen,  181 
Disease,   echinococeus,   of   uterus,   666 

of  pehis,  909 
gynecologic,  relation  of  insanity  to,  867 
hydatid,  666 
insanity  from,  867 
malignant,  of  uterus,  755 
marriage  as  cause  of,  432 
vesical,  303 
Diseases,  general,  152 
of  appendix,  308 
of  bladder,  303 
of  broad  ligaments,  955 

parovarian   cysts,   957 
of  cecum,  309 
of  external  genitals,  212,  432 

abscess  of  vulvo-vaginal  gland,  496 

adhesions,  525 

chancroid,  472 

condylomata,    499 

cyst  of  ATilvo-vaginal  gland,  498 

cysts,  503 

eczema,  457 

erysipelas,  455 

follicular  vulvitis,  454 

gangrene,   457 

gonorrhea,  431 

hematoma,  512 

hernia,  510 

herpes,  461 

hydrocele,  511 

injuries,   515 

intertrigo,  459 

kraurosis   vulvae,   516 

lacerations,  222 

malformations,  222 

malignant  disease,  487 

pediculosis,   462 

periurethral  abscess,  492 

phlegmonous  vulvitis,  456 

prolapse  of  urethral  mucosa,  494 

prurigo,  461 

pruritus  vulvae,  518 

pudendal  hernia,  509 

pudendal  hydrocele,  511 

scabies,  463 

sinus  of  A'ulvo-vaginal  gland,  497 

stasis  hypertrophy,  505 

syphilis,  479 

tuberculosis,  484 

tumors,  505,   704 

ulcers,  66,  219,  470 

ulcus  rodens  vulvae,  490 

urethral  caruncle,  494 

urethritis,  434,  445,  447,  492 

varicose  veins,  514 

vulvitis,  451 
of  Fallopian  tubes,  806,  834,  S68,  870,  907 


1136 


INDEX 


Diseases  of  Fallopian  tubes', — Cont'd 
catarrhal  salpingitis,  807 
displacements,  808 
neoplasms,  907 
salpingitis,  807,  834 
of  intestines,  321 
of  kidneys,  318 
of  labia,  221,  431 
of  liver,  194 

of  ovaries,  807,  834,  910 
acute  ovaritis,  806 
carcinoma,  953 
chronic  ovaritis,   846 
cystic  tumors,  923 
cysts  of  corpus  luteum,  925 
dermoid  cysts,  939 
fibroma,  953 
follicular  cysts,  923 
hemorrhage,  900 
inflammation,  807,  834 
oophoritis,  808 
ovaritis,  806,  846 
papillary  cysts,  931 
papillomata,  931 
paroophoritic  cysts,  955 
prolapse,  848 
sarcoma,  953 
solid  tumors,  953 
of  peritoneum,  324 
of  spleen,  194 
of  ureters,    262 
of  urethra,  492 
caruncle,  494 
polypi,   494 
prolapse,  494 
suburethral  abscess,  251 
urethritis,  492 
of  uterus,  577,  702,  755 

anteflexion,  702 

cancer  of  body,  755 

cancer  of  cervix,  755 

cervical  polypi,  625 

classification,  597 

displacements,  275,  669 

endocervicitis,  603 

endometritis,  623 

eversion  of  cervix,  598 

fibromata,  704 

gonorrheal  endometritis,   633 

hyperinvolution,  659 

hyperplasia  of  endometrium,  628 

hypertrophy  of  cervix,   624 

inflammation,  633 

infravaginal  hypertrophy  of  cervix,  258 

inversion,  261,  703 

lacerations  of  cervix,  608 

localization,  597 

posterior  versions  and  flexions,  671 

prolapse,  696 

sarcoma,  755 

sclerosis,  660 

senile  endometritis,  634 

septic  endometritis,  633 

subinvolution,  657 

supravaginal  hypertrophy   of   cervix,   258 


Diseases  of  uterus,— Cont 'd 
syphilis,  666 
tuberculosis,  664 
ulcer  of  cervix,  601 
of  vagina,  431 

acquired  atresia,  966 
acquired  stenosis,  966 
adhesive  vaginitis,  468 
cancer,  488 
chancroid,  472 
cystocele,  559 
cysts,  503 

diphtheritic  vaginitis,  467 
emphysematous  vaginitis,   467 
fibromata,  505 
gonorrheal  vaginitis,  434 
hernia,  509 

hyperesthesia  of  vaginal  entrance',  523 
malignant,  488 
parasitic  vaginitis,  466 
prolapse  anterior  wall,   558 
prolapse  posterior  wall,  558 
rectocele,  558 
sarcoma,  489 
senile  vaginitis,  468 
simple  ulcers,  470 
simple  vaginitis,  463 

syphilis,  479  - 

tuberculosis,  486 
tumors,  505 
vaginal  flatus,  477 
vaginitis,  431,  463,  467 
of  vulva,  431 

adhesions  of  clitoris,  222,  525 

adhesions  of  labia,  222,  525 

anterior  hernia,  510 

benign  tumors,  505 
cancer,  487 

chafing,  459 

chancre,  479 

chancroids,  472 

condylomata,  499 

cysts,  503 

cysts   of   vulvo-vaginal   glands,   498 

diphtheria,  459 

eczema,  459 

edema,  229 

elephantiasis,  230,  448 

erysipelas,  455 

fibroma,  505 

follicular  vulvitis,  218,  454 

gangrene,  457 

gonorrheal  A'ulvitis,   431 

hematoma,  229,  512 

herpes,  461 

hypertrophy  of  clitoris,  339,  443 

inflammation    of    ducts    of    vulvo-vaginal 
glands,  496 

inflammation     of     vulvo-vaginal     glands, 
496 

inguino-labial  hernia,  510 

intertrigo,  459 

kraurosis  vulvae,  516 

lipoma,  505 

malignant,  487 


INDEX 


1137 


Diseases  of  vulva, — Cont'd 

myoma,  505 

myxoma,  505 

parasitic  diseases,  462 

phlegmonous  vulvitis,  456 

prurigo,  461 

pruritus  vulvae,  518 

sarcoma,  487 

simple  ulcers,  470 

simple  vulvitis,  451 

stasis  hypertrophy,  230,  505 

syphilis,  479 

tuberculosis,  484 

tumors  of  clitoris,  239 

ulcus  rodens  vulvae,  490 

vaginismus,  523 

varicose  veins,  230,  514 

venereal  ulcers,  470 

verrucae,   499 
of  vulvo-vaginal  gland,  496 

abscess,  496 

cyst,  496 

inflammation,   496 
urethral,  67 
venereal,  431,  472,  479 
Disinfection,  hand,  1072 

methods  of,  1072 
in  examination,  140 
of  abdomen,   1069 
of  hands,  141,  1072 
of  vagina,  542,  645 
of  A^ilva,  542 
Disorders  of  menstruation,  972  {See  Menstru- 
ation) 
Displacement,  classification  of  causes  of,  •671 
of  bladder,  725 
of  Fallopian  tubes,  845 
of  kidneys,  310 
of  ovaries,  845 
of  uterus,  275,  669 

anteflexion,  702 

as  a  whole,  669 

backward,  671 

classification,  671 

inversion,  703 

normal  position  of  uterus,  670 

of  primary  importance,  671 

of  secondary  importance,  702 

pessaries  in  treatment.  371 

posterior    flexions,    671 

posterior  versions,  671 

prolapse,  696 

retrodisplacement,   671 

retroflexion,  671 

retroversion,  671 
supports  of  uterus,  670 
of  vagina,  254 
posterior,  671 
Dissecting  forceps,  543 
Distended  bladder,   179 
Distention,  intestinal,  172 

of  abdomen,   172 
Disturbances,  functional,  972 

sexual,   1017 
Diverticulum   of   urethra,   245 


Dorsal  posture,  63 
Double  uterus,  968 

vagina,  222,  967 
Douche,  hot  vaginal,  358 

intrauterine,  396 

pitcher,  1104 

vaginal,  353 
Douglas,  cul-de-sac  of,  36,  37 
Drainage,  abdominal,  1076 

after-treatment  in,  1095 

capillary,  1095 

dressings  in,   1095 

gauze  in,  1098 

glass  tube  in,  1095 

in   abdominal   section,    1095    {See  Abdom- 
inal   section) 

in  pelvic  abscess,  817 

in  peritonitis,  828 

of  bladder,   576 

peritoneal,   828 

rubber  tube,   817,  1097 

split-tube,    1097 

vaginal,  817 
Drains,  rubber,  818,  1097 
Dress  corrections,  413 

in  gynecologic  treatment,  413 
Dressings,  abdominal,   1075,   1095    {See    Ab- 
dominal   dressings) 

in   drainage,   1095 

vulvar,  653 
Dry  heat  in  gynecologic  treatment,  350 
Ducrey  bacillus,  472 
Duct  "of   Gartner,   921,   963 

of   Mueller,   961 

oviducts,  36,  528,  799 

vulvo-vaginal   gland,   67 

Wolffian,  960 
Dudley's    operation    for    dysmenorrhea,    1011 
Dullness     in     abdomen,     59,     195    {See    Ab- 
domen) 

in  ascites,  196 
Duration   of  menopause,   975 

of  menstruation,    974 
Dysmenorrhea,    993 

causes   of,    996,    1014 

Dudley's  operation  for  1011 

in  the  married,  1014 

in  the  virgin,  995 

membranous,  995,  998 

treatment   of,    1002,   1015 

varieties   of,   993,   995 
Dyspareunia,    1017 

treatment  of,  1019 

E 

Echinococcus  disease  of  pelvis,  909 

of  uterus,  666 
Ectopic     gestation,     873      {See     Extrauterine 

pregnancy) 
Ectropion   of   cervix,   273 
Eczema  of  external  genitals,  457 
Edebohl  's   speculum,   644 
Educated   touch,    99 


1138 


INDEX 


Effects   of  curetment.   655 
Electricity,   399 

apparatus  required,  399 

application,   400 

in  tibroniTOma,  729 
Electro-cauterv,   398 
Electrotherm,    350 
Elephantiasis  of  labia,  230,   505 

of   vulva,    230 
Elongation  of  cervix  uteri,  624 
Emmenagogues,   981 
Emmet's   operation   for  lacerated  cervix,   613 

for  lacerated  pelvic  floor,  552 
Emphysematous    vaginitis,    467 
Encysted   fluid,   175 
Endocervicitis,    603,    641 

acute,    603 

chronic,   606 

diagnosis  of,  604 

gonorrheal,  604 
Endocrin    glands,    1035    {See    Internal    secre- 
tion) 
Endometritis,    633 

acute,   633,   637 

applications  for,   637,   643 

bacteria  in,  633 

causes   of,   633,   638 

chronic,    638 

classification  of,  597 

curetment   for,   644 

diagnosis    of,    634,    637 

exfoliative,  998 

fungous,    639 

glandular,   655 

gonorrhea   of,    633 

hemorrhagic,    339 

infected,   606 

interstitial,   640 

pathology   of,    633,   638 

polypoid,   639 

prophylaxis   of,    634 

senile,   634 

septic,    633 

simple,    637,    642 

s;sTnptoms   of,   634,   640 

treatment  of,  636,  642 

tubercular,    642 

varieties  of,  597 
Endometrium,  anatomy  of,  583 

at  menstruation,  584 

carcinoma    of,    789 

epithelium   of,   583 

glands   of,  584 

gonorrheal,  633 

hyperplasia  of,  628 

inflammation  of,  633 

of  adult,    584 

of  infant,  583 

pathologic  changes,   595 

regeneration  of,   655 

senile,  587 

tuberculosis  of,  642 


Endothelioma,   761 
Enemata,  404 
high.  404 
laxative,  1100 
low,  404 
nutritive,  830 

directions  for  giving,  830 
indications  for,  830 
materials  for,   830 
postoperative,  830,  1100 
preoperative,  1069 
Enlarged    liver,    percussion    of    abdomen    in. 
195 
spleen,  percussion  of  abdomen  in,  194 
uterus,  percussion  of  abdomen  in,   191 
Enterocele,  vulvar,  510 
Enteroclysis,  829 
Epigastric  region,  183,  192 
Epithelioma  of  cervix,  755 
of  vagina,  329,  488 
of  vulva,  221  244,  487 
Epithelium  of  cervical  mucosa,  590 
of  endometrium,   583 
of  vagina,  430 
of  vulva,  423 
Erect  posture,  34,  35 
Ergot  in  fibromyoma,   728 
Erosion,  follicular,  599 
of  cervix  uteri,  598 
papillary,  599 
Erysipelas  of  external  genitals,  455 
Ether   for   examination,    127 

for  operation,  1073 
Eversion  of  cervical  mucosa,   372,   608 
causes  of,  608 
diagnosis  of,  611 
treatment  of,  613 
Examination,   gynecologic,   33    {See  note   un- 
der  Index) 
abdominal,  46,  164 
anatomy,  46 
inspection,  46 
palpation,  46 
regions,  49 

special   points   of   tenderness,   54,   56 
mass,  56 

fluid  wave,  57,  58 
fat  wave,  57,  58 
percussion,  59 
auscultation,   60 
mensuration,  61 
prominence,  46,  164 
obesity,  165 
mass  in  wall,  167 
ventral  hernia,  169 
relaxation  of  wall,  169 
separation  of  recti,   172 
tympanites,   172 
fecal  impaction,  172 
ascites,    174 
encysted  fluid,   175 
pregiiant  uterus,  178 


INDEX 


1139 


Examination,  abdominal  "prominence, — Cent  'd 
distended  bladder,   179 
pelvic   tumor,    180 
abdominal  tumor,  180 
discoloration  of  wall,  46,   181 
movement  of  wall,  181 
tenderness,    54,    183 
tension   of   abdomen,  46,   182 
in  right   lower   abdomen,   185 
in  left     lower  abdomen,  188 
in  central  lower  abdomen,   188 
in  lumbar  region,  190 
in  right  upper   abdomen,  190 
in  left  upper  abdomen,  190 
in  central   upper   abdomen,   190 
in  umbilical   region,   190 
diffuse,   191 
mass  felt,  191 

in  right  lower  abdomen,  191 
in  left  lower  abdomen,  191 
in  central   lower    abdomen,    191 
in  right  upper  abdomen,  192 
in  left  upper  abdomen,  194 
in  central  upper  abdomen,  194 

dullness,  59,  195 
from  liver,  195 
from  spleen,  195 
from  pregTiant  uterus,  193 
from  distended  bladder,  193 
from  ascites,  196 
from  encysted  fluid,  201 
from  pelvic  tumor,  202 
from  abdominal  tumor,  203 
from  kidney  tumor,  207 
from  perirenal  lipoma,  208 
of  external  genitals,  62,  209 

anatomy,  63,  209 

discharge,   62,   212 

inflammation,  66,  217 

ulcer,   66,   219 

swelling,  66,  228 

new   growth,   68 

malformation,    222 

hymen,   69 

perineum,  69 

laceration,  69,  222 
vaginal   (digital),  69,  262 

method,    69 

vaginal  walls,  73,  262 

base  of  bladder,  73 

urethra,  74 

■\Tilvo-vaginal  gland,  75 

pelvic  floor,  75 

rectum,   79 

cervix  uteri,  80,  270 

pericervical  tissues,  83 
vagino-abdominal  (bimanual),  83,  275 

uterus,   84,  277 
position,  88,   277 
size,  88,  280,  281 
shape,  88 
consistency,  88,  282 


Examination, vagino-abdominal,  utcrus,-Cont  'd 
tenderness,  88,  288 
mobility,  88,  290 
attachments,  88,  290 
displacement,  277 
enlargement,  280,  281 
softening,  282 
hard  nodules,  288 
lateral   regions,   89 
tube,  91 
ovary,    91 
ureter,  97 
educated  touch,  99 
train  one  hand,  102 
use  two  fingers,  103 
deep  examination,  103 
drawing   down   uterus,   104 
position  of  examiner,  105 
varying  conditions,  105 
intestines  in  way,  105 
diminish  tenderness,  106 
mass  or  induration,  291 
in  right  lower,  firm,  291 
in  right  lower,  fluid,  296 
in  left  lower,  299 
behind,    firm,    299 
behind,  fluid,   301 
in  front  lower,  firm,  303 
in  front  lower,  fluid,  303 
filling  lower  pelvis,  firm,   305 
filling   lower  pelvis,   fluid,   307 
in  right  side,  high,  firm,  307 
in  right  side,  high,  fluid,   313 
in  left   side,   high,   320 
in  median,  high,  firm,  320 
in  median,  high,  fluid,  325 
table  of  diagnostic  points,  327 
recto-abdominal  palpation  in,   107 
disadvantage,  107 
when  useful,  107 
of  virgin,  108 

recto-vagino-abdominal,   109 
palpation  of  coccyx  in,  110 
instrumental.  111 
by  speculum,  111 
instruments,   111 
steps,  114 

information  to  obtain,  116 
difficulties,   118 
cylindrical  speculum,   119 
Sims'    speculum,    119 
by  excision  of  tissue,  123 
by  sounding  uterus,  123 
steps,  123 
indications,  124 
contraindications,  124 
information    to    obtain,    124 
by  curetting,   125 
of  vaginal  walls,  330 
congestion,  330 
bleeding,   330 
ulcer,  330 
of  cei-vdx,   334 
normal,    334 


1140 


INDEX 


Examination,  instrumental,  of  cervix, — Cont'd 
discharge,  334 
lacerated,  334 
eroded,  334 

malignant  disease,  336 
under  anesthesia,  127 

preparations,  127 

vagino-abdominal    palpation,    128,    275 

recto-abdominal  palpation,  128 

reeto-vagino-abdominal  palpation,  131 

recto-vesical  palpation,  132 

curetment,  134 

•collecting  curettings,  134 

exploration    of    interior    of    uterus    with 
finger,  136 

excision  of  tissue,  138 

inspection  of  uterine  interior,  137 
radiography,  137 
preparations  for,  138 

office  arrangements,  138 

directions  to  patient,  140 

antiseptic  preparations,  140 

soap,  144 

brushes,  144 

lubricant,  144 

rubber  gloves,   145 

specimens,  149 
non-gynecologic  examination  methods,  152 

urine,   152 

blood,  153 

sputum,  157 

nervous  system,   158 
Examination,   abdominal,  46,   164    {See  note 
under  Index) 
abdomino-rectal,    107 
abdomino-vaginal,  83,  275 
anesthesia  for,  127 
antisepsis  in,  140 
antiseptic  preparations  for,  140 
bacteriologic,  66 

for  gonococci,  435 

securing  discharge  for,  65 
bimanual,  84,  275 

of  uterus,  84 
brush  in,    144 
by  lamp,  118 
digital,  of  vagina,  69 
disinfection  in,   140 
ether  for,  127 
gloves  in,  69 

gynecologic,  33,   {See  note  under  Index) 
history  in,  33 
in  bed,  150 

in  standing  posture,  81 
instrumental,  111 

by   curet,   125,   134 

by  excision,  123,  138 

by  Sims'   speculum,  119 

by  sound,  123 

by  speculum.  111 
intrauterine,  asepsis  in,  142 
judgment  in,  44 
knee-chest  posture  in,  106 
left  hand  in,  102 


Examination, — Cont  'd 
methods   of,   44 
methods,  classification  of,  44 

non-gynecologic,   152 
microscopic,  of   curetting,  138,   770 

of  excised  tissue,  138,  770 

of  pus,  65,  435 
of  abdomen,  46,  63 
of  Bartholin's  glands,  65 
of  blood,  153 
of  cervix  uteri,  80,  270 
of  coccyx,  110 

of  endocrin   gland   system,    159 
of  external  genitals,  62,  209 
of  Fallopian  tubes,  91 
of  kidney,  310 
of  nervous  system,  158 
of  ovary,  91 
of  pelvic  floor,  75 
of  rectum,   79 
of  sputum,  157 
of  ureter,  97 
of  urethra,  75 
of  urine,  152 
of  uterus,  84 
of  vagina,   69,  111 
of  virgin,  108 
of  vulva,  62 

of  vulvo-vaginal  glands,   75 
office  arrangements  for,  138 
order  of,  44 
pelvic,  83,  127 
physical,  44 
preparations  for,  138 
radiography  in,  137 
record  of,  43 
rectal,  79,  108 
recto-abdominal,   107 
recto-vagino-abdominal,   109,   131 
rubber  gloves  in,   145 
soap  in,  144 
specimens   from,    149 
two  fingers  in,  103 
tympanites  in,  172 
under  anesthesia,  91 

curetment,  134 

digital,  of  uterine  cavity,  136 

excision  of  tissue,  138 

recto-abdominal,   118 

recto-vagino-abdominal,  131 

recto-vesical,  138 

vagino-abdominal,  128 
uterine  digital,  136 
vaginal,  69,  261 

asepsis  in,  141 
vagino-abdominal,  83  275 

Fallopian  tubes,  91 

general  observations,  84 

lateral  regions,  89 

other  regions,  95 

ovaries,  96 

uterus,  84 
when  required,  44 


INDEX 


1141 


Examining^  fingers,  70 

hand,   70 

table,  139 
Excessive  menstruation,   988 
Excised    tissue,    microscopic    examination    of, 

138,  770 
Excision,  examination  by,  123 

of  condylomata,  499 

of  vulva,  499 
technic   of,   499 

of  warts,  501 
Excrescence,  cauliflower,   337 
Exercise,  416 

Exfoliative  endometritis,  998 
Exploration,  intrauterine,  136 

of  uterus,  125 
Exploratory     abdominal    section,     775,     1065 
(See  Abdominal  section) 

curetment,   125,  134 

vaginal   section,   1082 
Exstrophy  of  bladder,  178 
External  genitals,  421 

adhesions  of,  525 

anatomy  of,  64,  209,  421 

blood  vessels  of,  426,  427 

caruncle  of,  494 

chancroid  of,  472 

condylomata  of,  231,  499 

cysts  of,  503 

diseases  of,  421    (See  Diseases) 

eczema  of,  457 

erysipelas  of,  455 

examination   of,   62,   209 

gonorrhea  of,  431 

hematoma  of,  512 

hernia  of,  509 

herpes  of,  461 

hydrocele  of,  511 

hyperesthesia  of,  523 

inflammation  of,  66,  217 

injuries  of,  515 

inspection  of,  62,  209 

intertrigo  of,  459 

kraurosis  vulvae,  516 

lacerations   of,   222 

malformations   of,   222 

malignant  disease  of,  486 

pediculosis  of,  462 

periurethral  abscess  of,  492 

prurigo,   461 

pudendal  hernia,  509 

swelling  of,  66,  228 

syphilis  of,  479 

tumors  of,  485,  505 

ulcers  of,  66,  219 

ulcus  rodens  of,  490 

urethral  caruncle,  494 
mucosa,  494 

urethritis  of,  434,  492 

varicose  veins  of,  514 

vulvitis,  451 
Extirpation  of  vulva,  509 
Extracts,  animal,  418 

of  ovary,  922 


Extrauterine  fetus,  321 
gestation,   873 
pregnancy,    causes    of,    873 

ampullar,   875 

diagnosis   of,   882 

hemorrhage  in,  785 

interstitial,  286,  879 

pain  in,  884 

shock  from,   886 

signs  of,  888 

symptoms,  882 

treatment    of,    900 
Exudates,  291 
pelvic,  808,  836 

F 

Face  mask  for  operator,  1072 
Fallopian  tubes,  799 

accessory,  874 

adhesions  of,  838,  845 

amputation  of,  1085 

anatomy  of,  799 

anomalies  of,  873,  965 

carcinoma  of,   907 

conservative  operations  on,  1085 

conservative   surgery   of,    1085 

development  of,  963 

diseases  of,  (See  Diseases) 

displacement  of,  845 

examination   of,   91 

hemorrhage  from,  897,  904 

infection   of,   808 

inflammation  of,  808 

malformation  of,  965 

malignant  disease  of,  907 

neoplasms  of,  907 

occlusion  of,  834 

palpation  of,  91 

papilloma  of,  907 

resection  of,  1088 

rudimentary,  874 

rupture  of,  875 

tuberculosis  of,   870 

tumors  of,  907    " 
Fat  in  abdominal  wall,  164   (See  Abdominal 

wall) 
Fatty  degeneration,  720 
Fecal  fistula,  561 
Female  form,  34 
Fermentation  fever,  1101 
Fetal  heart  sounds,  60 

movements,  59 

uterus,   580 
Fetus,    calcareous    degeneration    of,    321. 

extrauterine,    321 
Fever,  154 

aseptic,  1101 

fermentation,  1101 

in  leucocytosis,  155 
Fibroid,   amyloid  degeneration  of,   720 

cases,  classification  of,  709,  710 

cervix,   710 

complication,  741 

cystic  degeneration  of,  720 


1142 


INDEX 


Fibroid,— Cont'd 

deg-eneration   of,    720 

diffuse,  710 

hemorrhage  in,  723 

interstitial,   704 

intraligamentary,  709 

metrorrhagia  from,  723 

necrotic,   717 

ox  round  ligament,  505 

of  uterus,  radical  treatment  for,  733 

pedieulated,  707 

submucous,  709 

subperitoneal,  707 

uterine,  atrophy  of,  704 

sarcoma  of,  719 
wandering,  709 
Fibroma  of  labia,  246 
Fibromyoma,  causes  of,  704 
classification  of,  704 
curetment  in,  729 
degeneration  of,   720 
diagnosis  of,  724 
diffuse,  710 
electricity  in,  729 
ergot   in,   728 
interstitial,  704 
iutraligamentary,  709 
intramural,  704 
of  uterus,   704 
operation  for,  733 
palliative  treatment  of,  728 
pathology,  704 
retroperitoneal,  709 
sarcoma  of,   719 
submucous,   709 
subperitoneal,  707 
suppuration  of,  717 
symptoms  of,   723 
treatment  of,  727 
Fibromyomata,  multiple,   706 
Finger-cots,  141 
Fingers,  examining,  69 
Fissure,  anal,  79 
Fistula,  561 

classification  of,  561 
denudation  in,  570 
fecal,  561 
recto-vaginal,  561 
uretero-vaginal,  566 
urethro-vaginal.    566 
vagino-rectal,  561 
vagino-vesical,  566 
vesico-vaginal,  566 

treatment,    568 
vesico-uterine,  575 
ureteral,  575 
uretero-uterine,  575 
Fixation  of  uterus,  682,  774 

ventral,  686 
Fixing  specimens,  149 
Flatus  vaginalis,  539 
Flaxseed  poultice,  673 
Flexion  of  uterus,  673 
Floor,  pelvic,  528 


Fluid,   encysted,   175 
Follicles,  Graafian,  911 
Follicular  cysts,  923 

degeneration  of  cervix,  606 

erosions,  599 

vulvitis,  218,  454 
Folliculi,  hydrops,  923 
Footrests,  adjustable,  139 
Forceps,  artery,  543 

Crossen's    puncturing    tenaculum,    692 

dilating,  126,  644 

dissecting,  543 

hemostatic,   543 

sponge,    543 

tenaculum,  615 

tissue,  543 

uterine,  644 

vaginal,  644 
Foreign  bodies  in  abdomen,  1077,   1118 

in  vagina,  379 

in  uterus,  1007 
Form,  female,  34 
Fourchette,  423 
i'owler  position,  828 
Friction  rubbing,  412 
Fulminating  pelvic  edema,  905 
Function,  testing,  of  kidney,  1068 
Functional  disturbances,  972 
Fungous  endometritis,  639 
Fiirbringer 's  method,  1072 

Cr 

Gall-bladder,  190 
Gangrenous  vulvitis,  457 
Gartner,  canal  of,  961 

duct  of,  961 
Gas  in  intestines,  172 
Gauze  drainage,  1098 

in  drainage,  1098 

iodoform,   822 

packing,  368 

strip   sponges,  1080 

tampons,  368 
Gehrung  pessary,  387 
General  anesthesia,  127,  1073 

debility,  153 

diseases,  153 

peritonitis,    822 
Genitalia,  421 
Genitals,  external,  421 

blood  vessels  of,  426,  427 

diseases  of,  421    (See  Diseases) 

examination    of,    62,    209     (See    Examina- 
tion) 
Gestation,     ectopic,     873      (See  Extrauterine 
pregnancy) 

extrauterine,  873 

in  septate  uterus,  968 

in  uterine  horn,  308 

normal,  478 

tubal,  873 
Gilliam-Crossen  operation,   688 
Gilliam-Ferguson  operation,  688 
Gilliam  operation,   688 


INDEX 


1143 


Gland  duet,  vulvo -vaginal,  67 
Glands,  Bartholin's  abscess  of,  239,  496 
anatomy  of,  67,  425 
examination  of,  67 
palpation  of,  67 
l%Tiiphatic,  592 
of  cervix,  585 
of  endometrium,  584 
Skene's,  424 

infection  of,  66,  446 
of  urethra,  424 
vulvo-vaginal,  67,  425 
abscess  of,  496 
anatomy  of,  67,  425 
carcinoma  of,  245 
cysts  of,  498 
discharge  from,  67 
examination   of,   75 
gonorrhea  of,  446 
infection  of,  66,  496 
inflammation  of,  496 
palpation   of,   67 
Glandular  endometritis,  655 
Glass  drainage  tube,  1095 
tube  in  drainage,  1095 
Gloves,  boiling,  147,  1070 
in  examination,   69 
rubber,    69    (See   Rubber   gloves) 
Glycerine,  145 

Gonococci,  bacteriologic  examination  for,  435 
Gonococeus,  435 

staining,  435  ^    • 

Gonorrhea,  431 
cause  of,  431 
chronic,  440 

diagnosis  of,  434 ;  serum  test,  160 
diplococcus  of,  437 
gonococeus,   435 
in   children,   450 
latent,  432 

of  external  genitals,  431 
of  Falloi^iau  tubes,  854 
of  vulvo-vaginal   gland,  446 
of  uterus,  633,  637 
pathology  of,  433 
s^-mptoms  of,  434 
treatment  of,  440 ;   vaccines,  419 
Gonorrheal  endocervicitis,  604 
endometritis,  633,  637 
maculae,  435 
salpingitis,  854,  857 
urethritis,    434 
vaginitis,   434 
vulvitis,  434 
Graafian   follicles,   911 
Gram's  method,  439 
Graves'  speculum,  112 

G^mecologic  diagnosis,  163   (See  Diagnosis) 
abdomen  in,  164 
backache  in,  343 
cervix  uteri  in,  270,  334 
corpus  uteri  in,  275 
methods  of,  163 
pain  in  pelvis  in,  337 


Gynecologic  diagnosis, — Cont  'd 

pelvic  mass  in,  291 

table  for,  327 

vaginal,  261 

vulvar,   261 
disease,  relation  of  insanity  to,   867 
examination,  33 

abdominal,   46    (See  Examination) 

bacteriologic,  432 

bimanual,  84,  275 

digital,  69,  262 

history  in,  33 

instrumental,  111 

of   external   genitals,   62    (See   Examina- 
tion) 

of  virgin,   108 

order  of,  46 

palpation  of  cocej-x  in,  110 

pelvic,  82 

physical,  46 

preparations  for,  138 

record  of,  43 

reeto-vagino-abdominal,  109,  131 

under  anesthesia,  127 

vaginal,  69   (See  Examination) 

vagino-abdominal,    83,   275    (See    Exami- 
nation) 

when  required,  45 
postures,  414 
pressure    treatment,    411 
records,   43 
therapy,  345 
treatment,  internal,  417 

intrauterine,   391    (See  Treatment) 
Gynecologv  in  relation  to  internal  secretions, 

1035 
Gynecology,  x-ray  in,  390 


H 


Hand  brushes,  144 

sterilization  of,   144 

disinfection,  1072 
methods  of,  1072 

examining,  69 
Hands,  disinfection  of,  140,  1072 

sterilization  of,  140,  1072 
Hard-rubber  disk  pessaries,  384 
Head  mirror,  119 
Heart  sounds,  fetal,  60 
Heat,  348,  350 
Hematocele,  pelvic,  876 
Hematocolpos,  224 
Hematoma,  intraligamentary,  295 

of  broad  ligament,  295 

of  external  genitals,  512 

of  vulva,  512 

pelvic,  295 

pudendal,  512 

subperitoneal,  878,  881 

vulvar,  229,  512 
Hematometra,   224 
Hematosalpinx,   897 
Hemoglobin,  153 


1144 


INDEX 


Hemorrhage    from    Fallopian    tube,    897,    904 

from  ovary,  904 

:n  cervical  polypi,  625 

in  extrauterine  pregnancy,  875 

in  fibroids,  723 

in  tubal  pregnancy,  875 

intraperitoneal,  875 

pelvic,  904 

postoperative,  1098 

shock  from,   886 

subcutaneous,  512 

tampon  for,  370 

treatment  for,  900 

uterine,  216 

vulvar,  512 
Hemorrhagic  endometritis,  639 
Hemostatic  forceps,  543 
Hermaphroditism,  969 
Hernia,  509 

abdominal,  169 

inguinal,  510 

inguino-labial,  510 

of  external  genitals,  510 

pudendal,  509 

umbilical,  168 

vaginal,  510 

vagino-labial,  510 

ventral,  169 

vulvar,  510 
Herpes  of  external  genitals,  461 

of  vulva,  461 
Hewitt  pessary,  389 
History  cards,  43 

in  examination,  33 

marriage  in  the,  37 

record,  35,  42 

taking,  33 
Hodge  pessary,  371 
Holder,  leg,  645 
Home,  operation  in,  1067 
Horizontal  posture,  45 
Hospital,  operation  in,  1067 
Hot  air  chamber,  356 

pastes,  349 

rectal  irrigation,   405 

stupes,  348 

vaginal  douche,  358 

water  bag,  350 
coil,  350 
Hottentot  apron,  242 
Hydatid  cyst,  667 

disease,  667 

mole,  667 
Hydatidiform  mole,  667 
Hydrocele  of  external  genitals,  511 
Hydronephrosis,  298,   317 
Hydrops  foUiculi,  923 
Hydrosalpinx,  318,  836,  842 
Hydrotherapy,  412 
Hydro-ureter,  298 
Hymen,  69,  209,  425 

absence  of,  1114 

anatomy  of,  209,  425 
anomalies  of,  209 


Hymen, — Cont  'd 

atresia  of,  224 

development  of,  961 

imperforate,  224 

malformation   of,   222 

rudimentary,  1116 
Hyperesthesia  of  external  genitals,   523 
Hyperinvolution  of  uterus,  659 
Hyperplasia  of  endometrium,  628 
Hypertrophy  of  cervix  uteri,  624 

"of  clitoris,  239,  243 

of  labia,  244,  505 

stasis,  230,  505 

operation   for,    509 

supravaginal,  258 
Hypodermoclysis,  1099 
Hypogastric  region,  52 
Hypospadias,  965 
Hysterectomy,   abdominal,   733,   751 

partial,  1087 

supravaginal,   733 

total,  733 

vaginal,  733 

varieties  of,  733 
Hysteria,  158 


Ice  bag,  351 
Ichthyol,  365 

Idiopathic  hypertrophy  of  cervix,  624 
Ileus,  1102 

Iliac  thrombosis,  1102 
Illumination,    118 
Imperforate  hymen,  222 
diagnosis  of,  222,  966 
illustration  of,  223 
symptoms  of,  966,  978 
treatment  of,  966 
Impotency,  1019 
Incision,  1074 
abdominal,   1074 
care,  1075 
closure,  1075 
dressing,  1075 
removing  sutures,  1092 
strapping,  1092 
suturing,   1075 
cervical,  closure  of,  618 
for  cervix  repair,  615 
for  pelvic  floor  repair,  552 

Emmet's,   552 
perineal,  closure  of,  555 
suprapubic,  1074 
Incomplete  abortion,  38 
Incontinence  of  urine,  576 
Indecent  assault,  1108 

Indications  for  abdominal  section,  1066    (Sec 
Abdominal  section) 
for  conservative  surgery,  1085 
for  knee-chest  posture,  416 
for  nutritive  enemata,  830 
for  operation,  1066 
for  repair  of  cervix,  613 
I       for  repair  of  pelvic  floor,  541 


INDEX 


1145 


Induced  aloortioii,  751 
Induration,  Tesieal,  303 
Infant,  endometrium  of,  583 
Infantile  uterus,  578 
Infected  endometritis,  606 
Infection,  799 

localized,   1101 

of  abdominal  wound,   1100 

of  cervical  wound,  620 

of  cervix  uteri,  603 

of  corpus  uteri,  633 

of  Fallopian  tubes,  808 

of  lymphatics,  762 

of  ovarian  tumor,  947 

of  ovaries,  808,  836 

of  peritoneum,  822 

of  Skene's  glands,  447 

of  urethra,  492 

of  uterus,  606 

of  vagina,  434,  463 

of  veins,  809 

of  vulva,  451 

of  vulvo-vaginal  glands,  66,  496 

puerperal,  633,  807 
Inflammation,  799 

acute    pelvic,  807     {See    Acute    pelvic    in- 
flammation) 

chronic  pelvic,  833    {See  Chronic  pelvic  in- 
flammation) 

leucocytosis  in,  156 

of  endometrium,  606 

of  external  genitals,  Q6,  217 

of  Fallopian  tubes,  808 

of  ovary,  808,  836 

of  pelvic  connective  tissue,  808,  843 

of  urethra,  492 

of  uterus,   633 

of  vagina,  434,  463 

of  vulva,  451 

of  vulvo-vaginal  gland,   QQ,  496 

opiates  in,  813 

pelvic,  189 

prophylaxis  of,  807 

purgatives  in,  813,  851 

rest  in,  347,  813 

retrodisplacement  with  acute,  683 
with  chronic,  684 
Inflated  ring  pessaries,  372,  383 
Infusion,   intravenous,   1098 
Inguinal  adenitis,  477 

hernia,  510 
Inguino-labial  hernia,  510 
Injections,  intrauterine,  396 

intravenous,  1098 

rectal,  404 

subcutaneous,  1098 

vaginal,  353 
Injuries  from  labor,  533,  608 

of  bladder,  1077 

of  cervix,   608 

of  external  genitals,  515 

of  intestines,  1077 

of  ureter,  1077 

of  uterus,  608 

of  vulva,  515 


Insanity  from  disease,  867 

postoperative,  867 

relation  of,  to  gynecologic  disease,  867 
Inspection  of  abdomen,  46 

of  cervix  uteri,  216 

of  external  genitals,  62,  209 

of  pelvic  cavity,  1075 

of  vaginal  walls,  215 

of  vulva,  62,  209 

of  uterus,  137 
Instrument   sterilizer,   142 
Instrumental  examination.  111  {See  Examina- 
tion) 

by  curet,  125,  134 

by  excision,  123 

by  Sims'  speculum,  119 

by  sound,  87,  123 

by  speculum.  111 
Instrumentation,  intrauterine,  123 
Instruments,  boiling,  142 

for  curetment,  645 

for  repair  of  cervix,  615 

for  repair  of  pelvic  floor,  543 

sterilization  of,  142 
Interglandular  relation,  1038 
Intermenstrual  pain,  1015 
Internal  secretions,  1035 

and  gynecologic  therapy,  1057 

cause  of  gynecologic  anomalies,  1050 

chemical  nature,  1037 

definition,  1036 

historical  facts,  1035 

influence  on  genital  apparatus,  1040 

interglandular  relation,  1038 

relation  to  gynecology,  1035 
Interstitial  endometritis,  640 

extrauterine  pregnancy,   286 

fibroids,  704 

fibromyoma,   704 

pregnancy,  286,  879 
Intertrigo,  459 

of  external  genitals,  459 
Intestinal  distension,  172 

movement,  181 

obstruction,  1100 

paralysis,  1100 

tenderness,  188 

tympany,  172 
Intestines,  adhesions  of,  838 

diseases  of,  321 

gas  in,  172 

injuries  of,  1077 
Intraligamentary  cyst,  297 

fibroid,  709 

fibromyoma,  709 

hematoma,  295 
Intramural  fibromyoma,  704 
Intraperitoneal  hemorrhage,  875 
Intrauterine  applications,  391 

douche,   396 

examination,  asepsis  in,  142 

exploration,   136 

injections,   396 

instrumentation,   123 

treatment,  391   {See  Treatment) 


1146 


INDEX 


Intravenous  infusion,   1098 

injections,  1098 
Introduction  of  pessary,  377 
Invasion  of  peritoneal  cavity,  1065 
Inversion  of  uterus,  261,  703 
Iodoform   gauze,   822 
Irregular  menstruation,  1016 
Irrigation,  hot  rectal,  405 

of  uterine  cavity,  396 

of  vagina,  353 
Irritable  uterus,   659 
Ischio-reetal  abscess,  291 
Ischuria,   1100 
Isthmic  pregnancy,  875 


Japanese  stove,  350 


K 


Kidney,  186 

diseases  of,  318 

displacement  of,  310 

examination  of,  310 

movable,  186 

pain  in,  40 

palpation  of,  310 

tenderness  of,  55 

testing  function  of,  1068 

tumor   of,   208 

wandering,  315 
Knee-chest  posture,  414 

description  of,  414 

in  examination,  106 

in  gynecologic  treatment,  414 

in  pelvic  tumor,  416 

in  prolapse,  416 

in  puerperium,  416 

in  retrodisplacement,   679 

indications  for,  416 
Kraurosis  vulvae,  516 

causes  of,  516 

diagnosis  of,  517 

pathology  ot,  517 

prognosis  of,  517 

symptoms  of,  517 

treatment  of,  517 

X-ray  in,   517 


Labia,  209,  421 

adhesions  of,  222,   525 

diseases  of,  221,  431 

elephantiasis  of,  236 

fibroma  of,  246 

hypertrophy  of,  244 

majora,  421 

malformation   of,   222,   525 

minora,  422 

adherent,  222,  525 

stasis  hypertrophy  of,  505 

structure   of,  421 
Labor,  injuries  from  533,  608 


Lacerated    cervix,     Emmet's     operation     for, 
613 
pelvic  floor,  Emmet 's  operation  for,  552 
Lacerations,  222,  527 
of  cervix,  332,  608 
causes,  608 
complications,  611 
diagnosis,  611 
examination,  612 
operation,   613 
pathologic  changes,  609 
prognosis,  621 
symptoms,  611 
treatment,  613 
varieties,  608 
of  external  genitals,  222 
of  pelvic  floor,  222,  533 
causes,   534 . 
diagnosis,  75,  222,  534 
Emmet's  operation,   552 
pathology,  534 
symptoms,   538 
treatment,  540 
of  perineum,  222,  533 
of  sphincter  ani  muscle,  539 
of  vulva,  222 
Lamp,  examination  by,  118 
Laparotomy,  1065  (See  Abdominal  section) 
Latent  gonorrhea,  432 
Lateral  regions,  palpation  of,  89 
Lavage,  827 
Laxative  enemata,  1100 
Legholders,  645 
Leucocytosis,  155 
in  diagnosis,  155 
in  fever,  155 
in  inflammation,  156 
in  pain,   155 
Leucorrhea,  1025 

causes  of,   213,   1026 
in  children,  465 
significance  of,  213 
treatment   of,    1028 
Levator  ani  muscle,  528 
Life,  change  of,  975 
Ligament,  broad,  593 
tumor  of,  312 
varicose  veins  of,  908 
round,  593 
anatomy,   593 
fibroids  of,  505 
myoma  of,  312 
operations  on,  686 
transplantation  of,  688 
tumor  of,  312 
sacro-uterine,  593 
vesico-uterine,    593 
Ligatures,  543,  615 
LiiDoma  of  uterus,  754 

of  vulva,  505 
Liquid  soaj),  144 
Lithopedion,   321 
Liver,  diseases  of,  190 

enlarged,  percussion  of  abdomen  in,  195 


INDEX 


1147 


Local  anesthesia,  106,  365 
Localized  infection,  1101 

tenderness,  56 
Louse,  pubic,  462 
Lubricants,  144 
Lupus  vulvae,  484 

X-ray  in,  486 
Lymphangitis,  456 
L_^^nphatic  glands,  592 
Lymphatics,   infection  of,   762 

of  uterus,  593 

of  vagina,  430 
,    of  vulva,  427 

M 

Maculae,  gonorrheal,  435 

Malaria,  155 

Maldevelopment  of  internal  genitals,  relation 

to  internal  secretion,  1051 
Malformations,   960 
congenital,  222,  960 
of  bladder,   179 
of  cervix,  290 
of  clitoris,  222,  239 
of  external  genitals,  222 
of  Fallopian  tubes,  874,  965 
of  hymen,  222,  966 
of  labia,  222,  525 
of  ovary,  965 
of  prepuce,  525 
of  urethra,   965 
of  uterus,  968 
absence,  979 
bicornis,  968 
didelphys,  968 
double,  965 
duplex,  965 
infantile,  997 
rudimentary,  965 
septate,  965 
unicornis,  968 
of  vagina,  224,  966 
of  vulva,  222,  487 
Malignant  degeneration,   755 
disease  of  cervix  uteri,  755 
of  corpus  uteri,  789 
of  external  genitals,  486 
of  Fallopian  tubes,  907 
of  ovaries,  953 
of  uterus,  755 
of  vagina,  488 
of  vulva,  487 
Malposition  of  uterus,  275 
Mammary  gland  preparations,  1064 
Marriage  as  cause  of  disease,  432 
contraindications  to,  432 
sterility  in,   1020 
Married,  dysmenorrhea  in  the,  1014 
Mass  in  abdomen,  56,  150   {See  Abdomen) 
Massage  in   gynecologic  treatment,   405 
pelvic,  405,  412 
application,  406 
indications,  405 
contraindications,  410 


Masturbation,  422 

Materials  for  nutritive  enemata,  830 

Measurements,    61 

Medico-legal  points  in   gynecology,   1108 

Melancholia,  158 

Membranous  dysmenorrhea,  995,  998 

Menge  pessary,   385 

Menopause,  587 

bleeding  in,   975 

definition  of,  975 

diagnosis  of,  975 

duration  of,  975 

metrorrhagia  in,  976 

physical  changes  in,  587 

sjTnptoms  of,  975 

synonyms  of,  975 

time  for,  975 

treatment  of,  976 
Menorrhagia,  988 

causes  of,  988 

diagnosis  of,  989 

pathologic  significance  of,  988 

relation  to  internal  secretion,  1053 

symptoms  of,  989 

treatment  of,  990 
Menses,   suppression   of,   988 
Menstruation,  584 

absence  of,  976 

definition  of,  972 

delayed,  1016 

diagnosis  of,  974 

disorders  of,  972 
amenorrhea,  976 
delayed  menstruation    1016 
dysmenorrhea,    995 
menorrhagia,   988 
precocious  menstruation,  1016 
retarded  menstruation,  1016 
vicarious  menstruation,  1016 

duration  of,  974 

endometrium  at,  584 

excessive,  988 

normal,  972 

painful,  993 

physical  changes  in,  584 

physiologic  significance  of,  975 

precocious,  1016 

relation  of  puberty  to,  973 

retarded,   1016 

scanty,  988 

synonyms  of,  974 

time   for,   973 

treatment  of,  975 

vicarious,  1016 
Mensuration  of  abdomen,  61 
Mesenteric  cyst,  180 
Metastasis,  764 
Method,  Apostoli,  729 

Fiirbringer 's,  1072 

Gram's,  439 
Methods   in   gynecologic   treatment,   345 

non-gynecologic  examination,   152 

of  diagnosis,  163   {See  Diagnosis) 

of  examination,  33 


1148 


INDEX 


Methods, — Cont  'd 

of  hand   disinfection,    1072 

of  replacement,  679 
Metritis,  633 

acute,  633 

chronic,  638 
Metrorrhagia,  215 

causes  of,  1030 

definition  of,  988 

diagnosis  of,   1035 

from  abortion,  38,  1031 

from  cancer,  766 

from  fibroid,  723 

from  polyp,  625 

from  tubal  pregnancy,  883 

in  menopause,  976 

relation  to  internal  secretion,  1055 

symptoms  of,   990 

treatment  of,  990 
Microscopic  examination  of  curetting,  134,  769 

of  excised  tissue,  138,  770 

of  pus,  435 
Mirror,  head,  119 
Moist  heat  in  gynecologic  treatment,  348 

warts,  499 
Mole,  hydatid,  667, 
Mons  veneris,  421 
Morgagni,  cyst   of,   922 
Movable  kidney,  186 

retrodisplacement,  678 
Movement,  intestinal,   181 

fetal,  59 

of  abdomen,  181 

of  abdominal  wall,  181 
Mucosa,  cervical,  epithelium  of,  597 
eversion  of,  372,   608 

urethral,  prolapse  of,  240,  494 
Muellerian  ducts,  960 
Multilocular  ovarian  cyst,  936 
Multiple   condylomata,   499 

fibromyomata,  706 
Muscle,  levator  ani,  528 
Muscles,  recti,  172 

separation  of,  172 

transverse  perineal,  529 
Mustard  plaster,  352 
Mycotic  vaginitis,  466 
Myoma,  cervical,  704 

of  round  ligament,  312 

of  uterus,  704 
Myomectomy,  733,  751 

abdominal,  733 
Myometrium,  582 
Myxomatous    degeneration,    720 

N 

Nausea,  1099 
Necrobiosis,    720 
Necrosis,    720 
Needle  holder,  543,  615 

Sims',  543 
Needles,  543,  615 
Neoplasms  of  Fallopian  tubes,  907 

of  ovaries,  910 


Neoplasms, — Cont  'd 

of  uterus,  263,  282,  704 

of  vagina,  487,  505 

of  vulva,  488,  505 
Nephritis,  152 
Nephroptosis,  314 
Nerve  trunks,   102 
Nerves,  pelvic,   102 
Nervous  system,  examination   of,  158 
Neuralgic  dysmenorrhea,  993 
Neurasthenia,  158 
Neuromata  of  vulva,  523 
Neuropathic  dysmenorrhea,  996 
Neuroses,  158,  182 

New  growths  about  external  genitals,  68 
Nodular  salpingitis,  838 
Nodule  in  cervix,  271 
Noma  of  vulva,  457 

Non-gynecologic  examination  methods,  152 
Normal  gestation,  478 
Nuck,    canal   of,    510 
Nurse,  139 
Nutritive  enemata,  830 

directions  for  giving,   830 

indications   for,   830 

materials  for,  830 
Nymphae,  209,  421 
Nymphomania,   523 

O 

Obesity,   166 

abdomen  in,   166 
Obstruction,  intestinal,  1100 

of  bowels,  1100 

to  coitus,   1017 
Obstructive   dysmenorrhea,  994 
Occlusion  of  cervix,  290 

of  Fallopian  tubes,  834 

of  vagina,  966 
Office  arrangements,  138 

assistant  in,  139 
Oidium  albicans,  466 
Ointment,  Crede's,  395 
Oophorectomy,  1086 
Oophoritis,  808,  846 

suppurative,  808,  836 
Operation,  abdominal,  1065 

Alexander,  Adam 's,  686 

anesthesia  for,  1073 

asepsis  in,  1069   {See  Asepsis) 

assistant  in,  1071 

bowels  after,  557 
before,   1069 

cervix,  denudation  in,  617 

technic  of,  615   {See  Technic) 

complications  of,   1095 

conservative,  in  salpingitis,   1085 
on  Fallopian  tubes,  1085 

contraindications  for,  1066 

Crossen's  retrodisplacement,   692 

cystocele,  technic  of,  559 

dilatation  of  cervix,   1095 

Dudley's,  for  dysmenorrhea,  1011 

Emmet's,  for  lacerated  cervix,  613 


INDEX 


1149 


Operation, — Cont'd 

for  lacerated  pelvic  floor,  552 

ether  for,  1073 

for  anteflexion   of   cervix,    1010 

for  cancer  of  uterus,  775 

for  displacement,    classification    of,    686 

for  fibromyoma,  733 

for  lacerated   sphincter   ani,   552 

for  pelvic  inflammation,  813 

for  prolapse,  702 

for  relaxation  of  pelvic  floor,  544 

for  retrodisplacement,  685 

for  stasis  hypertrophy,  509 

for  vesico-vaginal  fistula,  569 
.Gilliam,  688 

Gilliam-Ferguson,  688 

in  gynecologic  treatment,  420 

in    home,  1067 

in  hospital,    1067 

indications  for,  1066 

in  salpingitis,   851 

on  round  ligament,   686 

opiates  after,  1090 

pelvic  floor,  denudation  in,  552 

plastic,   613 

Porro,   751 

preparation  for,  1067 

prognosis  in,   866 

purgatives    after,    1090,    1100 
before,  1069 

rest  after,  1093 

Schroeder's,   on   cervix   uteri,   623 

teehnic  of,  552  (See  Technic) 

vaginal,  1082 

vomiting  after,   1099 

water  after,  1090 
before,  1069 

Wertheim's,    779 
Operator,  face  mask  for,  1072 
Opiates  after  operation,  1090 

in  inflammation,  813 
Organo-therapy,  1059 
Organs,  pelvic,  33,  36 
Orgasm,   sexual,    1019 
Os,  pin-hole,  1021 
Outlet,  vaginal,  530 
Ovariotomy,  1086 
Ovarian  abscess,  808,   836 

cysts,  923 

multilocular,    936 

function,   1041 

pregnancy,  880 

preparations,   1062 

stroma,  911 

thrombosis,   810 

tumors,  910 
infection,  947 
Ovaries,  910 

accessory,  965 

adhesions   of,   838 

anatomy  of,  910 

anomalies  of,  965 

blood  vessels  of,   591 

cancer  of,   953 


Ovaries,^ — Cont  'd 

carcinoma  of,   953 

cirrhosis    of,    847 

conservative   surgery   of,    1085 

cystadenoma   of,  927 

cystic  degeneration  of,  923 

dermoid  of,  939 

development  of,  963 

diseases  of,  910    (See  Diseases) 

displacement  of,  845 

examination  of,  91 

extract   of,   920 

hemorrhage   from,    904 

infection   of,   808,   836 

inflammation  of,  808 

malformation   of,   965 

malignant  disease  of,  953 

neoplasms  of,  810,  923,  953 

palpation  of,  91 

papilloma  of,  934 

physiology  of,  918 

preservation  of   during  operation,  1086 

prolapse  of,  848 

removal  of,  1014 

resection  of,  1086 

rudimentary,  965 

sarcoma  of,  953 

serous  cyst  of,  931 

solid  tumor  of,  953 

supernumerary,   965 

tuberculosis    of,    868 

tumor  of,  922 

vessels  of,  591 
Ovaritis,  808 
Oviducts,  36,  598,  799 
Ovulation,   916 
Ovum,  918 
Oxalic  acid,  1072 


Packing,   368 

gauze,  368 

vaginal,  368 
Pads  and  sponges,  929,   1010,  1077 
Pain,  337 

in  coitus,   1018 

in  extrauterine  pregnancy,   896 

in  kidney,   40 

in  pelvis   in   gynecologic   diagnosis,    337 
(See  Diagnosis) 

intermenstrual,  1015 

leucocytosis  in,  155 

localized,  55 

reflected,  343 
Palliative  treatment,  judgment  in,  821 

treatment  of  fibromyoma,  728 
Palpation,  abdominal,  46,  191 

bimanual,  83 

digital,  69,   262 

of  abdomen,  46 

of  Bartholin's  glands,  68 

of  coccyx,    110 

of  Fallopian   tubes,   91 

of  kidneys,  310 


1150 


INDEX 


Palpation, — Cont  'd 

of  lateral  regions,  89 

of  ovaries,   91 

of  ureters,   97 

of  uterus,    84,    275 

of  vulro-vag'inal   gland,    68 

recto-abdominal,   107,   128 

recto-vagino-abdominal,    109,    131 

recto-vesical,   132 

vaginal,   69,'  262 

vagino-abdominal,   83,   128 
Pancreas  preparations,  1064 

relation   to    gynecology,   1050 
Panhysterectomy,    733 
Papillary   cyst,    931 

erosion,    539 
Papilloma  of  Fallopian  tube,  907 

of  ovary,  934 
Paquelin    cautery,    786 
Paralysis  from  anesthesia,  1073 

intestinal,   1100 
Parametritis,  843 
Parametrium,   777 
Parasites,    Tulvar,    462 
Parasitic  diseases  of  vulva,  462 
Parathyroid    glands,    relation    to    gvneeologv, 

1047 
Paroophoron,   922 
Parovarian   cyst,   955 
Parovarium,    922 

anatomy  of,   922 

tumors  of,   955 
Partial  amputation  of  cervix  uteri,  621 

hysterectomy,  1087 
Parturition,   535,   609 

Pathologic  significance   of  menorrhagia,  988 
Pathology  of  endometritis,  637,  638 

of  kraurosis  vulvae,  517 

of  papillary  cysts,  931 

of  peritonitis,  822 

of  pruritus   vulvae,    518 

of  salpingitis,  729,  807,  834 

of  tubal  pregnancy,  874   {See  Tubal  preg- 
nancy) 
Patients,  judgment  in  explanation  to,  866 
Pediculated  fibroid,  707 
Pediculosis  of  external  genitals,  462 
Pediculus  pubis,  462 
Pelvic  abscess,  291,  808   (See  Abscess) 
after-treatment  in,  820 
bacteria  in,  853 
drainage  in,  817 

affections,  boTvels  in,  813,  1069 

anatomy,   33,   577,    799 

cavitv,  inspection  of,  1075 

cellulitis,  808,  843 

connective  tissue,  inflammation  of,  805,  844 

edema,  905 

examination,  127 

exTidates,  808,  836 

floor,  75,  528 
anatomy  of,  527 
blood  vessels  of,  529 
examination  of,  75 


Pelvic  floor, — Cont'd 

Emmet's  operation  for  lacerated,  552 
incision  for  repair  of,  547,  552    {See  In- 
cision) 
instruments  for,  543 
lacerations  of,  533   (See  Lacerations) 
operation,  technic  of,  547   {See  Teehnic) 
operations,  denudations  in,  552 
relaxation  of,  533 

repair,    incision    for,    547,    552    {See    In- 
cision) 
repair  of,  547  {See  Eepair) 
suturing  of,  553 
tears  of,  533 
g;s-necologic  examination,  46 
hematocele,  876 
hematoma,  295 
hemorrhage,  904 
inflammation,  799 

acute,   799    {See   Acute   pelvic   inflamma- 
tion) 
chronic,  833    {See  Chronic  pelvic  inflam- 
mation) 
prophylaxis  of,  807 
mass    in    gynecologic    diagnosis,    291    {See 

Diagnosis) 
massage,  405 
nerves,  102 
organs,   33,  36 
peritoneum,  804 
peritonitis,  822 
suppuration,  835 
tulDereulosis,  868 
tumor,  704,  755 

knee-chest  posture  in,  416 
Pelvis,    antero-posterior   section    of,    34.    35 
congestion  of,  864,  989 
echinococcus  disease  of,  909 
pain  in,  in  gynecologic  diag-nosis,  334 
pus  in,  808,  836 
tenderness  in,  93 
tuberculosis  of,  868 
Percussion  of  abdomen,  59  •  • 

deep,  59 
superficial,  59 
Perineal  incision,  closure  of.  555 
Perineorrhaphy,  540   {See  Pelvic  floor) 
after-treatment  in,  555 
preparations  for,  540 
Perineum,  69 

lacerations  of,  (See  Lacerations) 
suturing  of,  555 
Perirenal  tumor,  208 
Peritoneal  drainage,  828,  1095 
Peritoneum,  593 
anatomy  of  593 
diseases  of,  324 
infection  of,   822 
inflammation  of,  824 
laceration  of,  533 
repair  of,  544 
tuberculosis  of,  868 
Peritonitis,   822 
acute  diffuse,  808 


INDEX 


1151 


Peritonitis, — Cont  'd 

causes  of,  807 

causes  of,  801 

diagnosis  of,  811 

drainage  in,   824 

general,  822 

pathology  of,  807 

pelvic,  822 

symptoms  of,  810 

treatment  of,  824 

tubercular,  868 
Periurethral  abscess,  492 
Pessaries,  371 

action  of,  372 

care  of,  382 

cup  and  belt,  390 

flexible  ring,  384 

for  cystocele,  389 

for  prolapse,  384 

for  retrodisplacement,  371,  681 

Gehrung,  387 

hard-rubber  disk,   384 

Hexs-itt,  389 

Hodge,  371 

in  gvnecologic  treatment,  371 

inflated  ring,  372,  383 

instruction  to  patient  using,  379 

introduction  of,  377 

Menge,  385 

selection  of,   374 

Smith,  372 

stem,   1007 

Thomas,   372 

varieties  of,  371 
Phagedenic  chancroid,  477 
Phlebitis.  1102 
Phlegmasia    dolens,    763 
Phlegmonous  vulvitis,  456 
Physical  change  in  menopause,  587 
in  menstruation,  587 

examination,  44 
Phvsiologic  sigTiincance  of  menstruation,  975 
Pincus,  atmocausis  of,  398 
Pineal  gland,  relation  to  g}-necology,  1049 
Pin-hole  OS,  1021 
Pitcher  douche,  1104 
Pituitary  gland  preparations,  1064 

relation  to  gynecology,  1048 
Placental  remnants,  137 
Plaster,  adhesive,  1092 
Plastic  operation,  613 
Points,    special,    in    abdominal    section,    1076 

(See  Abdominal  section) 
Poh^pus,  metrorrhagia  from,  (525 
Polypi,  275,  625 

cervical,  625 

hemorrhage  in,  628 

of  cervix  uteri,  625 
Poh^oid  endometritis,  639 
Porro  operation,  751 
Position  of  arms  during  anesthesia,  1017 

of  uterus,  669 
Posterior  displacements,  669 


Postoperative  adhesions,  1100 

enemata,  1100 

hemorrhage,  1098 

insanity,  867 

vomiting,  1098 

t^Tupanites,  1100 
Posture,   dorsal,   63 

erect,  34,  35 

Fowler,  828 

g^mecologic,  414 

horizontal,  45 

knee-chest,  414 

description  of,  414 

in  examination,  106 

in  gynecologic  treatment,  414 

in  pelvic  tumor,  416 

in  prolapse,  416 

in  puerperium,  416 

knee-chest,    414 

in  retrodisplacement,  679 
indications  for,  416 

left  lateral,  120 

semi-prone,  119 

Sims,  119,  120 

Trendelenburg,  416 
Powders,  in  treatment,  366 
Precocious  menstruation,  1016 

pubertv,  relation  to  internal  secretion,  1053 
Pregnancy,  176,  278,  284 

abdomen  in,   176,  279,   290 

ampullar,  875 

auscultation  in,  60 

carcinoma  complicating,  784 

diagnosis  of,  159;   serum  test,  159 

extrauterine,    873    (See   Extrauterine    preg- 
nancy) 

in  uterine  horn,  308 

interstitial,  286,  879 

istlimic,  875 

tubal,  875 
hemorrhage  in,  876 
pathology  of.  874  (See  Tubal  pregnancy) 

wandering,  880 
Preoperative  enemata,  1069 
Preparations    for     abdominal     section,     1067 
(See  Abdominal  section) 

for  anesthesia,  1068 

for  curetment,  645 

for  examination,  138 

for  operation,   1067 

for  perineorrhaphy,  540 

for  repair  of  cervix,   613 

for  repair  of  pelvic  floor,  540 

for  trachelorrhaphy,    613 

for  vaginal  section,  1084 

of  operator,  1071 
Prepuce,  adherent,  222,  525 
Preservation  of  specimens,  149 
Pressure  treatment,  411 
Proctoclysis,  829 
Prognosis  in  operation,   866 

of  kraurosis  vulvae,  517 

of  papillary  cysts,  938 

of  salpingitis,  835,  866 


1152 


INDEX 


Prolapse,  knee-chest  posture  in,  416 

of  bladder,  228,  265 

of  ovary,  848 

of  urethral  mucosa,  240,  494 

of  uterus,  245 
causes,  696 
diagnosis,  699 
pathology,  696 
radical  treatment,  701 
symptoms,  697 
treatment,  700 
,   of  vagina,  228 

operation  for,  702 

pessaries  for,  384 

vaginal,  255,  558 
Proliferating  cysts,  926 
Prominence  of  abdomen,  164 
Prophylaxis  of  endometritis,  634 

of  pelvic  inflammation,  807 

of  retrodisplacement,   671 

of  shock,  1076 

of  subinvolution,  659 
Prurigo  of  vulva,  461 
Pruritus  vulvae,  518 

causes  of,  518 

diagnosis  of,  519 

pathology  of,  518 

symptoms  of,  519 

treatment  of,  520 

X-ray  in,  522 
Pseudohermaphroditism,  969 
Pseudomucinous  cysts,  927 
Pseudotuberculosis  of  peritoneum,  909 
Psychoses,  158 
Psycho-therapy,  420 
Puberty,  973 

relation  of,  to  menstruation,  973 
Pubic  louse,  462 
Pudendal  hematoma,  512 

hernia,  509 

hydrocele,  511 

tumor,  505 
Puerperal  abscess,  bacteria  in,  831 

infection,  633,  807 
Puerperium,  knee-chest  posture  in,  416 
Purgatives  after  operation,  1090,  1100 

before  operation,  1069 

in  inflammation,  813,  851 
Purulent  discharge,  63 
Pus  in  pelvis,  808,  836 

microscopic  examination  of,  435 
Putting  on  rubber  gloves,  145 
Pyemia,  bacteria  in,  854 
Pyometra,  282 
Pyosalpinx,  316,  317,  808,  835 

bacteria  in,  856 

Q 

Quadrants,  50 

Questions,  diagnostic  table  of,  327 
in  fibroid  cases,  727 


E 

Radical  treatment  for  cancer  of  uterus,  773 
for  fibroid  of  uterus,  733 
for  prolapse  of  uterus,  701 
for  salpingitis,  851 
Radium  in  treatment  of  carcinoma,  788 

of  fibromyoma,   731 
Rape,  1108 

of  children,  1110 
Reasons  for  conservative  surgery,  1085 
Rectal  applications,  404 
digital  examination,  128 
examination,  107 
injections,  404 
irrigation,  hot,  405 
Recti  muscles,  172 

separation  of,  172 
Records,   43  ■ 

diagrams  in,  43 
gynecologic,  43 
of  examination,  43 
Recto-abdominal  examination,  128 
Recto-abdominal  palpation,  128 
Rectocele,  228,  538,  558 
Recto-perineal  fistula,  561 
Recto-vaginal  fistula,  561 

Recto-vagino-abdominal  examination,  109,  131 
Recto-vesical  palpation,  132 
Rectum,  79 

carcinoma  of,  762 
examination  of,  79 
Regeneration  of  endometrium,  655 
Region,  epigastric,  51 
hypogastric,  51 
umbilical,  51 
Regions  of  abdomen,  51 
Regular  steps  in  abdominal  section,  1073  (See 

Abdominal  section) 
Relaxation  of  pelvic  floor,  527 
Relaxed   abdominal  wall,   169    (See  Abdomi- 
nal wall) 
vaginal  outlet,  75 
Remnants,  decidual,  137 

placental,  137 
Removal  of  ovary,  1014,  1086 

of  sutures,  951 
Renal  tumor,  167 
Repair  of  cervix,  613 

after-treatment  for,  619 
denudation  for,  617 
incisions  for,  615 
indications  for,  613 
instruments  for,  615 
preparations  for  615 
steps  in,  615 
sutures  in,  617 
of  pelvic  floor,  540 

after-treatment  for,  555 
denudation  for,  552 
incisions  for,  547,  552 
indications  for,  541 
instruments  for,  543 
preparations  for,  542 


INDEX 


1153 


Repair  of  pelvic  floor, — Cont'd 
steps  in,  547 

Emmet 's  operation,  552 
sutures  in,  553 
Replacement,  bimanual,  679 

methods  of,  679 

of  uterus,  679 
Resection  of  vaginal  outlet,  552 

of  ovaries,  1086 
Resonance,  corona  of,  194 
Rest,  347 

after  operation,  1093 

in  gynecologic  treatment,  347 

in  inflammation,  347 
Retarded  menstruation,  976 
Retention  of  blood,  222 

of  urine,  179 
Retractors,  vaginal,  543 
Retrodisplacement,  adherent,  677 

cases,  classification   of,  686 

causes  of,  671 

definition  of,  671 

diagnosis  of,  675 

knee-chest  posture  in,   679 

movable,  678 

of  uterus,  671 

operation  for,  685 

pessaries  for,  371 

prophylaxis  of,   671 

replacement  of.   678 

retroflexion,  671 
.  retroversion,  671 

symptoms  of,  674 

treatment  of,  678 

with  acute  inflammation,  683 

with  chronic  inflammation,  684 
Retroflexion,  671 
Retroperitoneal  fibromyoma,  709 

tumor,  182 
Retroposition  of  uterus,  275 
Retroversio-flexion,  671 
Retroversion,  671 
Retroverted  pregnant  uterus,  943 
Retr  over  ted  uterus,  275 
Right  lower  abdomen,  51,  191 
Rodent  ulcer,  490 
Rotation  of  cyst,  946 
Round  ligament,  593 

anatomy  of,  593 

fibroids  of,  505 

myoma  of,  312 

operations   on,   686 

transplantation  of,  688 

tumor  of,  312 
Routine  use  of  rubber  gloves,  147 
Rubber   dam,    1095 

drains,  817,  1097 

gloves,  145 

in  abdominal  section,  1071   (See  Abdomi- 
nal section) 
in  examination,  145 
putting  on,  145 
routine  use  of,  147 
sterlization  of,  146 


Rubber, — Cont'd 

tube  drainage,  817,  1097 
Rudimentaiy  Fallopian  tubes,  874 

hymen,  1116 

ovaries,   965 

uterus,  968 

vagina,  967 
Rupture  of  bladder,  179 

of  Fallopian  tubes,  875 

S 

Sacro-uterine  ligaments,  593 
Saline  solution,  829 
Salpingectomy,  744 
Salpingitis,  807,  834 

acute,  807 

bacteria  in,  807 

causes  of,  807,  834 

chronic,   834 

conservative  operation  in,  1085 

diagnosis  of,   811,   840 

gonorrheal,   854,   857 

mild,  807 

operation  in,  851 

pathology  of,  807,  834 

prognosis  of,  835,  866 

radical  treatment  for,  851 

suppurative,  808,  836 

symptoms  of,  811,  844 

treatment  of,  813,  851 

tubercular,  870 
Sarcoma  of  ovary,  953 

of  uterine  fibroids,  719 

of  uterus,  755 

of  vagina,  489 

of  vulva,  487 
Scabies,  463 

Scanty  menstruation,  988 
Scliroeder's  operation  on  cervix  uteri,  623 
Sclerosis  of  the  uterus,  660 
Scopolamin  in  anesthesia,  903 
Semi-prone  posture,  119 
Senile  bleeding,  975 

endometrium,  587,  634 

vaginitis,  468 

vulvitis,  467 
Separation    of    recti    muscles,    172    (See   Ab- 
dominal wall) 
Sepsis,  822 
Septate  uterus,  965 

gestation  in,  968 
Septic  endometritis,  633 
Serous  cystadenomata,  931 
Serum  test:     pregnancy,  159;  gonorrhea,  160 
Serum  therapy,  830 
Sexual  disturbances,  1017 

impotence,   1019 

orgasm,  1019 
Shape  of  abdomen,  47,   164 

of  abdomen  in  ascites,  174 
Shock,  1076 

causes  of,  1076 

from  extrr.uterine  pregnancy,  886 


1154 


INDEX 


Shock,— Cont'd 

from  hemorrhage,  886 

prophylaxis  of,  1076 

symptoms  of,  886 

treatment  of,  1098 
Significance  of  leueorrhea,  213 

of  menorrhagia,  989 

of  menstruation,  975 
Signs  of  ascites,  174 

of  extrauterine  pregnancy,  888 
Silkworm-gut,  553 
Silver  wire,  570 
Simple  endometritis,  637,  642 

ulcer,  470 

vaginitis,  463 

vulvitis,  451 
Sims'  needle-holder,  543 

posture,  119,  121 

speculum,  119,  120 
Sinus,  1103 

of  vulvo-vaginal  gland,  497 
Sitz-bath,  349,  352 
Skene  pessary,   387 
Skene's  glands,  424 

infection  of,  447 

of  urethra,  424 
Smith  pessary,  372 
Soap,  144 

in  examination,  144 

liquid,  144 
Soft  chancre,  472 
Solid  tumor  of  ovary,  953 

of  vulva,  485,  505 

of  uterus,  704 

saline,   829 
Solutions  in  treatment,  364 
Sound,  instrumental  examination  by,  123 

uterine,  123 
Special    points    in    abdominal     section,    868, 

1076  {See  Abdominal  section) 
Specimens,  fixing,   149 

from  examination,   149 

preservation   of,   149 
Speculum,  119 

bivalve,  111 

cylindrical,  119 

Edebohl's,  644 

examination  by.   111 

Graves',  112 

Sims',  119 

vaginal.  111 
Sphincter  ani,  539 

laceration  of,  539 

suturing  of,  552 
Spleen  diseases  of,  194 

enlarged,  percussion  of   abdomen  in,  194 
Split-tube  drainage,  1097 
Sponge  forceps,  543 
Sponges,  1080 

abdominal,   1080    {See  Abdominal   section) 

Crossen's  gauze-strip,  1029 

detached,   1080 
Sputum,  examination  of,  157 
Standing   posture,   examination   in,    81 


Stasis  hypertrophy,  230,  505 

of  vulva,  505 

operation  for,  509 
Stenosis  of  cervix,  605 

of  vagina,  967 
Steps   in   curetment,   646 

in  repair  of  cervix,  613 

in  repair    of    pelvic    floor,    549,    552    {See 
Repair) 
Sterility,  1020 

causes  of,  1021 

diagnosis,  1023 

relation  to  internal  secretion,  1056 

treatment  of,  1024 
Sterilization  of  abdomen,  1069 

of  abdominal  dressing,  914,  1070 

of  abdominal   surface,   1069    {See  Abdomi- 
nal section) 

of  catheters,    1105 

of  hand  brushes,   144 

of  hands,  140,  1072 

of  instruments,    142 

of  rubber  gloves,  69 

of  sutures,    1069 

of  vulva,  542 
Sterilizer,  instrument,  142 
Stimulants,  1098 
Stitch-hole  abscess,  1101 
Stomach,  acute  dilatation  of,  1099 
Streptococcic  infection  of  pelvic  cellular  tis- 
sue, 859 
Structure  of  labia,  421 
Stupes,  turpentne,  348 
Subcutaneous  hemorrhage,  512 

injections,  1098 
Subinvolution  of  uterus,  657 

prophylaxis  of,   659 
Submucous  fibromyoma,  709 

paraffin   injection,    786 
Subperitoneal  fibroid,   707 

hematoma,   878,   881 
Suburethral  abscess,  251 
Superficial  percussion  of  abdomen,  59 
Supernumerary  ovary,  965 
Supporter,   abdominal,   1093    {See  Abdomijial 
section) 

uterine,  384 
Supports  of  uterus,  670 
Suppositories,  vaginal,  367 
Suppression  of  menses,  987 
Suppuration  of  abdominal  wound,  1101 
diagnosis   of,  1101 
symptoms  of,  1101 
treatment  of,   1102 

of  fibromyoma,  717 

pelvic,  835 
Suppurative  oophoritis,  808,  836 

salpingitis,  808,  836 
Suprapubic  incision,  1074 
Supravaginal  amputation,  733 

hypertrophy,  258 

hysterectomy,  733 
Surface,  abdominal,  sterilization  of,  1069  {See 
Abdominal  section) 


INDEX 


1155 


Suspension,  ventral,  687 
Sutures,  buried,  553 

catgut,  553 

continuous,   553 

crown,  553 

in  abdominal  wound,  1075,  1092 

in  cervix,   617 

in     perineum,  555 

in  repair  of  cervix,  617 

in  repair  of  pelvic  floor,  547,  553 

removal  of,  1092 

sterilization   of,   1069 
Suturing-  of  levator  ani,  555 

of  pelvic  floor,  547,  553 

of  sphincter  ani,  552 

of  uterus  forward,  685 

of  vulva,  509 
Swelling  of 'external  genitals,  66,  228 

of  vulva,  229 
S^^nnptoms  of  amenorrhea,  976 

of  endometritis,  634,  640 

of  extrauterine  pregnancy,  882 

of  tibromyoma,    723 

of  gonorrhea,  434 

of  imperforate  hymen,  966 

of  kraurosis  vulvae,  517 

of  menopause,  975 

of  menorrhagia,   989 

of  metrorrhagia,    999 

of  ovarian  cysts,   939 

of  pelvic  inflammation,   810 

of  peritonitis,   810 

of  pruritus  vulvae,  518 

of  retrodisplaeement,   674 

of  salpingitis,  811,  844 

of  shock,  886 

of  suppuration   of   abdominal  wound,   1101 

of  tubal  pregnancy,  875 

of  vulvitis,  452 
SATicytioma  malignum,  792 
Synonyms  of  menstruation,   974 

of  tubal  pregnancy,  873 
Syphilis,  479 ;   Wassermann   reaction,   162 

of  external  genitals,  479 


T 


Table,   diagnostic,   of   questions,   327 

examining,  139 

for   gynecologic  diagnosis,   327 
Tablets,  in  treatment,  367 
Taking  history,  33 
Tampon-capsules,  371 
Tampons,  368 

for  hemorrhage,   370 

gauze,  370 

vaginal,   370 
T-bandage,  654 
Tears  of  pelvic  floor,  533 
Technic  of  cervix  operations,  617 
partial  amputation,  621 
regiilar  amputation,  625 

of  curetment,  646 

of  cystocele   operation.   559 

of  excision  of  vulva,  499 


Technic,— Cont'd 

of  pelvic  floor  operation,  547 
Emmet's,  552 
Tenaculum  forceps,  615 

Crossen's  puncturing,  692 
Tenderness  in  abdomen,  56,  183 
in  pelvis,  93 
intestinal,  188 
localized,  56 
of  kidney,  55 
urethral,  72 
vesical,  73 
Tension  of  abdomen,  46,  182 
Tents  for  dilating,  127 
Testing  function  of  kidney,   1068 
Therapeutic  curetment,  642 

measures,  classification  of,   345 
Therapy,   gynecologic,  345 

relation  to  internal  secretion,  1057 
Thomas  pessary,  372 
Thrombo-plilebitis,  809 

bacteria  in,  809 
Thrombosis,  broad  ligament,   809 
iliac,  810,  1102 
ovarian,  810 
septic,  808 
uterine,  810 
ThjTnus,  relation  to  gynecology,  1049 
Thyroid  gland  preparations,  1063 

relation  to  gAmecology,  1046 
Time  for  menopause,  975 

for  menstruation,   973 
Tissue  forceps,  543 
Total  hysterectomy,  733 
Towels,  boiling,  1070 
Trachelorrhaphy,  613 
after-treatment  in,  619 
preparations  for,  613 
Transplantation  of  round  ligament,  688 
Transverse  perineal  muscles,  529 
Traumatism  of  vulva,  515 
Treatment,  constitutional,  979 
bacterial,  419 
diet  in,  420 
exercise,  416 
for  hemorrhage,  900 
for  menopause,  976 
friction  rubbing,  412 
gynecologic,  345 
bathing  in,  412 
cauterization,  397 
cervical  dilatation,  404 
cold  in,  351 

counterirritatiou  in,  352 
curetment,  397 
dress  in,  413 
dry  heat  in,  350 
electricity,    399  . 
enemata,  404 
intrauterine,  391 

applications,  361,  391 
cauterization,  397 
curetment,  397 
dilatation,  404 


1156 


INDEX 


Treatment,  gynecologic,  intrauterine, — Cont'd 
electricity,  399 
irrigation,  396 
vacuum,  404 

knee-chest  posture  in,  414,  679 

local,    361 

massage  in,  405,  412 

methods  in,  345 

moist  heat  in,  348 

operations   in,    420 

pessaries  in,  371,  1007 

powders  in,  366 

pressure  treatment  in,  411 

psycho-therapy,   420 

rest   in,   347 

solutions  in,   364 

suppositories,  367 

tablets,  367 

tampon  capsules,  371 

tampons,  368 

vacuum,   404 

vaginal   applications  in,   361 

vaginal  douches  in,  353 

X-ray,  390  ■ 

internal,  417 
methods  of,  345 
of  amenorrhea,    979,   986 
of  bloody  discharge,  1032 
of  carcinoma,   773 
of  chancroid,  475 
of  chronic   gonorrhea,   446 
of  cystocele,  559 
of  dysmenorrhea,  1002,  1015 
of  endometritis,   638,   642 
of  eversion  of  cervical  mucosa,  613 
of  extrauterine  pregnancy,  900 
of  fibromyoma,   727 
of  gonorrhea,   440 

of  hyperesthesia  of  vaginal  entrance,  523 
of  imperforate  hymen,  966 
of  kraurosis  vulvae,  516 
of  leucorrhea,  1028 
of  menorrhagia,  990 
of  menstruation,   973 
of  ovarian  cysts,  951 
of  pelvic  floor  relaxation,   540 
of  pelvic  inflammation,  813,  850 
of  peritonitis,  824 
of  pruritus  vulvae,  520 
of  recto-vaginal  fistula,  561 
of  retro  displacement,  678 
of  salpingitis,  813,  851 
of  sarcoma,  794 
of  shock,   1098 
of  sterility,   1024 

of  suppuration  of  abdominal  wound,  1101 
of  syphilis,  483 

of  tubal  pregnancy,  900    (See  Tubal  preg- 
nancy) 
of  ulcers,  472 
of  urethral  caruncle,  495 
of  vesico-vaginal  fistula,  568 
of  vulvitis,   452 
organo-therapy,  1059 


Treatment, — Cout  'd 

palliative,   of  fibromyoma,   727 
radium,   731  . 
vaccine,  419 
vaginal,  353 
X-ray  in,  731 
Trendelenburg  posture,  416 
Trials,   criminal,   1124 
Trunks,  nerve,   102 
Tubal  abortion,  878 
abscess,  808,  834 
gestation,  873 
pregnancy,  873 
causes  of,  873 
diagnosis  of,  882,  888 
hemorrhage  in,  875 
metrorrhagia  from,  883 
pathology  of,  873 
carried  to  term,  880 
free  intraperitoneal  hemorrhage,  876 
hematocele,  875 
hematoma,  878 

mass  from  repeated  hemorrhage,  875 
tubal  abortion,  877 
symptoms  of,  882 
treatment  of,  900 
advance  cases,  904 
before  rupture,  900 
moderate  hemorrhage,  901 
pelvic  hematocele,  901 
pelvic  hematoma,  903 
profuse  hemorrhage,  901 
varieties  of,  875 
Tubercular  adhesions,  870 
endometritis,  642 
peritonitis,   869 
salpingitis,  870 
vaginitis,  486 
Tuberculosis,   tuberculin   test,   161 
of  endometrium,  642 
of  Fallopian  tubes,   870 
of  ovaries,  868 
of  pelvis,  868 
of  peritoneum,  869 
of  uterus,  664 
of  vagina,  486 
of  vulva,  484 
X-ray  in,  486 
Tubes,  blood  vessels  of,  803 
Fallopian,   799 
glass  drainage,  1095 
Tubo-ovarian  cysts,  925 
Tumor,   abdomen  in,   180 
of  abdomen,   180 
of  abdominal    wall,    167     (See    Abdominal 

wall) 
of  broad  ligament,   312 
of  external  genitals,  485,  505 
of  Fallopian  tube,  907 
of  kidney,  208 
of  ovary,   922 
of  parovarium,  955 
of  round  ligament,  312 
of  uterus,  704,  755 


INDEX 


1157 


Tumor, — Cont  'd 

of  vagina,   488,   505 

of  wlva,  485,  505 

ovarian,   922 

infection  of,  947 

pelvic,  704,  755 

knee-chest   posture   in,    416 

perirenal,   208 

pudendal,  505 

renal,  208 

retroperitoneal,  182 

solid,  of  ovary,  953 
of  uterus,  704 
of  vulva,  485,  505 

uterine,   704,   755 

vesical,  304 
Turpentine   stupes,   348 
Two  fingers  in  examination,  103 
Tympanites,   172 

abdomen  in,  172 

in  examination,  172 

postoperative,  1100 
Tympany,  intestinal,  172 


U 


Ulcers,  66,  219,  470 

of  cervix  uteri,   601 

of  external  genitals,  66,  219,  470 

of  vagina,   470 

of  vulva,  219,  470 

rodent,  490 

simple,  470 
Ulcus  rodeus,  490 

X-ray  in,  492 
"Umbilical  hernia,  168 

region,  51 
Unicornuate  uterus,  965 
Ureter  calculi  of,  292 

diseases  of,  292 

examination  of,  97 

injuries  of,  1077 

palpation  of,  97 
Uretero-vagiual  fistula,  566 
Urethra,  424 

anatomy  of,  424 

anomalies  of,  965 

carcinoma  of,  487 

caruncle  of,   494 

destruction  of,  576 

diseases  of,  431    (See  Diseases) 

diverticulum  of,  245 

examination  of,  74 

infection  of,  492 

inflammation  of,  492 

malformation  of,  964 

Skene's  glands  of,  424 
Urethral  abscess,  492 

caruncle,  494 

discharge,  66 

diseases,  67 

mucosa,  prolapse  of,  240,  494 

tenderness,  72 
Urethritis,  67,  431,  492 

acute,  64,  492 


Urethritis, — Cont  'd 

bacteria  in,  65 

chronic,  492 

gonorrheal,  434 
Urinalysis,   152 
Urine,    examination   of,   152 

incontinence  of,  576 
■  retention  of,  179 
Uteri,  corpus,   597 

Uterine    atrophy,    relation   to    internal    secre- 
tions, 1052 

cavity,  578 

irrigation  of,   396 

curet,   125,  650 

digital  examination,  136 

dilators,  126,  644 

diseases,    {See  Diseases  of  uterus) 

fibroids,   atrophy  of,   704 
sarcoma  of,  719 

forceps,  644 

hemorrhage,    216 

horn,  gestation  in,  308 
pregnancy    in,    308 

sound,  124 

supporter,  384 

thrombosis,  810 

tumors,   704,   755 
Uterus,  absence  of,  959 

adhesions  of,  682 

anatomy  of,  577 

anomalies  of,  966 

atresia  of,  282 

atrophy  of,  659 

bacteria  in,  633 

bicornuate,    968 

bimanual  examination  of,  84 

blood  vessels  of,  590        ^ 

cancer  of,  285,  334,  755 
radical  treatment  for,  773 

carcinoma  of,  755 

cirrhosis  of,  660 

classification  of   diseases  of,  596 

development    of,    962 

diseases  of,   596    (See  Diseases) 

displacement  of,   277,   669 

double,  968 

echinocoecus  disease  of,  666 

enlarged,    percussion    of    abdomen    in,    191 

examination   of,   84 

fetal,   580 

fibroid  and  pregnancy,   750 
.     fibroid   of,   radical   treatment   for,    733 

fibromyoma  of,  704  (See  Fibromyoma) 

fixation  of,  682,  774 

flexion  of,  673 

foreign  bodies  in,   1007 

forward,    suturing   of,    685 

gonorrhea  of,  633,  637 

hyperinvolution   of,   659 

infantile,  578 

infection  of,  606 

inflammation  of,  606 

injuries  of,  60S 

inversion  of,  261 


1158 


IXDEX 


Uterus, — Cont  'd 
irritable,   659 
lipoma  of,  754 
lymphatics  of,  593 

malformation  of,   968    {See  Malformation) 
malignant   disease  of,   755    {See  Malignant 

disease) 
malposition  of,  275 
myoma  of,  704 
neoplasms  of,  263,  282,  704 
non-malignant  tumors   of,   704 
operation  for   cancer  of,  775 
palpation  of,  84,  275 
position  of,   669 
pregnancy  and  fibroid,  750 
prolapse    of,    245,    696    {See    Prolapse    of 
uterus) 

radical  treatment  for,  707 
replacement    of,    679 
retrodisplacement  of,   671 
retroposition  of,  275 
retrorerted,  275 
rudimentary,   968 
sarcoma   of,    794 
sclerosis  of,  660 
septate,  965 

gestation  in,  968 
solid  tumor  of,  704 
subinvolution  of,  657 
supports  of,  670 
syphilis  of,  666 

tuberculosis    of,    664    {See   Tuberculosis) 
tumor  of,  704,  755 
uuieoruuate,  965 


Vaccine  treatment,  830 
Vacuum  treatment,  404 
Vagina,  33 

absence  of,   222 

anatomy  of,  421,  427 

anomalies  of,  966 

aphthae   of,   466 

atresia   of,  224,   966 

bacteria  in,  435,   463 

blood  vessels  of,  430 

carcinoma  of,  488 

chancroid,   472 

congenital  atresia  of,   222 

cysts,  503 

development  of,  962 

digital  examination  of,  69 

diseases  of,  261,  421    {See  Diseases) 

disinfection  of,  542,  645 

displacements  of,  254 

double,   222,   967 

epithelioma    of,    329,    488 

epithelium  of,  430 

examination  of,  69 

foreign  bodies  in,  379 

hyperesthesia  of  vaginal  entrance,  523 

infection    of,   434,   463 

inflammation  of,  434,  463 

irrigation   of,   353 


Vagina, — Cont  'd 
lymphatics  of,  430 
malignant  disease  of,  486 
malformation  of,  222 
neoplasms  of,  488,  505 
nerves,  430 
occlusion  of,  966 
prolapse  of,  228 
rudimentary,   967 
sarcoma  of,  489 
size,  427 
stenosis  of,  967 
syphilis,  479 
tuberculosis  of,  486 
tumors  of,  488,  505 
ulcers  of,  470 
vessels,  430 
Vaginal  antisepsis,  648 

applications,  353    {See  Applications) 

cyst,  261 

diagnosis,  261,  330 

digital  examination,  Q^,  262 

diseases,  463 

douche,  hot,  353 

in  g^mecologic  treatment,  353 
drainage,  817 
examination  69,  262   {See  Examination) 

asepsis  in,  140 
flatus,  539 
-   forceps,  644 
hernia,  509 
hysterectomy,  733 
injections,  353 
operation,  10^2 
■  after-treatment,  1103 
orifice,  dilatation  of,  524 
outlet,  530 

relaxed,  75 

resection  of,  552 
packing,  368 
palpation,  69,  263 

prolapse,  255,  504  , 

retractors,   543 
section,  1082 

advantages,  1082 

after-treatment  in,  1103 

anterior,  1082 

disadvantages,  1083 

preparations  for,  1084 

steps,  1085 
suppositories  and  cones,  367 
tampons,  368 
treatment,  353 
walls,  73 

adhesions  of,  468,  966 

conditions  of,  329 

inspection  of,  215 
Vaginismus,  523 
Vaginitis,  acute,  463,  468 
adhesive,  468 
bacteria  in,  432,  463 
causes  of,  431,  463 
chronic,  446,  467 
■diagnosis  of,  434,  465 


INDEX 


1159 


ginitis, — Coiit  'd 

iiphtheritic,  467 
mphysematous,  467 
onorrheal,  431 
1  cliildren,  465 
lycotie,  466 
arasitic,  466 
enile,  468 
imple,  463 

ubercular,  486 

varieties  of,  431 

gino-abdominal  examination,   83,   275    {See 
Examination) 

LTsterectomy,  733 

)alpation,  128 

gino-rectal  fistula,  561 

Lgino-reetal  fistula,   561 
aricose  veins,  237,  514,  908 

of  broad  ligament,  908 

of  external  genitals,  514 

of  vulva,  237,  514 
Varix  of  vulva,  237,  514 
Vegetations  of  vulva,  237,  499 
■'^eins,  calculi  of,  90S 

infection   of,    809 

varicose,  237,  514 
Venereal  diseases,  431,  472.  479 
Ventral  fixation,  686 

hernia,  169 

suspension,  687 
Vermiform  appendix,  308 
Verruca,  499 
Vesical  induration,  303 

tenderness,  73 

tumor,  304  * 

Vesicles,  herpetic,  461 
Vesieo-uterine  ligament,  593 
Vesico-vaginal  fistulae,  566 
Vessels  of  ovary,  591 
Vestibule,  209,  424 
Vicarious  menstruation,  1016 
Violence  in  coitus,  228 
Virgin,  amenorrhea  in  the,  977 

bimanual  examination  of,  108 

dysmenorrhea  in  the,  995 

g\Tiecologic  examination  of,  44 
Virus,  chancroidal,  475 
Vomiting,  1099 

after  operation,  1099 
Vulva,  62,  209 

anatomv  of,  209,  421 

atresia  of,  222 

blood  supply  of,  426 
vessels  of,  426 

carcinoma  of,  222,  487 

chancroid  of,  472 

condylomata  of,  231,  499 

contusion  of,  515 

cysts,  503 

diphtheria  of,  457 
■V    diseases  of,  431   {See  Diseases) 

disinfection  of,  542 

eczema  of,  457 

elephantiasis,  505 


Vulva, — Cont  'd 

epithelioma  of,  221,  244,  487 

epithelium  of,  423 

erysipelas  of,  455 

examination  of,  62 

excision  of,  499 

extirpation  of,  499 

follicular  vulvitis,  454 

gangrene  of,  457 

hematoma,  512 

herpes  of,  461 

infection  of,  431,  451 

inflammation  of,  431,  451 

injuries  of,  515 

inspection  of,  62,  209 

intertrigo,  459 

kraurosis  of,  516 
X-ray  in,  517 

lacerations  of,  222  {See  Lacerations) 

lipoma  of,  505 

lupus  of,  484 

Ivmphatics  of,  427 

nialformations  of,  222,  487 

malignant  disease  of,  486 

neoplasms  of,  488,  505 

neuromata  of,  523 

noma  of,  457 

parasitic  diseases  of,  462 

phlegmon  of,  456 

prurigo  of,  461 

pruritus  of,  518 
X-ray  in,  522 

rudimentary,  968 

sarcoma  of,  487 

simple  vulvitis,  451 

solid  tumor  of,  485,  505 

stasis  hypertrophy  of,  505 

sterilization  of,  542 

suturing  of,  509 

swelling  of,  228 

s^-philis  of,  479 

technic  of  excision  of,  499 

traumatism  of,  515 

tuberculosis  of,  484 

tumor  of,  485,  505 

ulcer  of,  222,  470 

ulcus  rodens  of,  490 

varicose  veins  of,  514 

varix  of  237,  514 

vegetations  of,  237,  499 

wounds  of,  515 
Vulvar  applications,  353,  364 

cellulitis,  456 

dermatitis,  451 

diagnosis,  61,  212   {See  Diagnosis) 

diseases,  451   {See  Diseases) 
classification  of,  431 

dressings,  653 

eczema,  457 

enterocele,  510 

hernia,  510 

hematoma,  229,  512 

hemorrhage,  512 

itching,  518 

parasites,  462 


1160 


INDEX 


Vulvitis,  451 
acute,  431,  451 
causes  of,  431,  451 
chronic,  451,  454 
diagnosis  of,  452 
diphtheritic,  457 
ervsipelas,  455 
follicular,  218,  454 
gangrenous,  457 
gonorrheal,  431 
intertrigo,  459 
senile,  467 
simple,  451 
symptoms  of,  452 
treatment  of,  452 
varieties  of,  431 
Vulvo-vaginal  abscess,  496 
cyst,  498 
gland,  67,  425 

abscess  of,  496 

anatomy  of,  67,  425 

carcinoma  of,  245 

cysts  of,  498 

discharge  from,  67 

duct,  67 

examination  of,  75 

gonorrhea  of,  446 

infection  of,  66,  496 

inflammation  of,  496 

palpation  of,  67 

sinus  of,  497 

W 

Waist  constriction,  413 

Wall,    abdominal,    46,    164     {See    Abdominal 
wall) 


Wall,  abdominal, — Cont  'd 
movement  of,  181 

vaginal,  73 
Wandering  fibroid,  709 

kidney,  315 

pregnancy,  880 
Warm  applications,  352 
W^arts,  499 

excision  of,  500 
Wassermann  reaction,  162 
Water  after  operation,  1090 

bag,  hot,  350 

before  operation,  1069 
Wave  in  ascites,  58 
Wertheim  's  operation,  779 
Wire,  silver,  570 
Wolffian  body,  960 

duct,  960 
W^ound,  abdominal,  1074   {See  Abdominal 
wound) 
infection  of,  1101 
suppuration  of,  1101 
sutures  in,  1070,  1092 

cervical,  infection  of,  620 

of  vulva,  515 


X-ray  in  cancer,  390,  788 
in  fibromyoma,  731 
in  gjaiecology,  390 
in  kraurosis  vulvae,  517 
in  lupus  vulvae,  486 
in  pruritus  vulvae,  522 
in  tuberculosis,  486 
in  ulcus  rodens,  492 


"\^ 


